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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseondiseasOOtutt 


A  TREATISE   ON 

DISEASES  OF  THE  ANUS 
RECTUM,  AND  PELVIC  COLON 


BY 
JAMES   P.  TUTTLE,  A.  M.,  M.  D. 

PROFESSOR   OF    RECTAL    SURGERY    IN   THE    NEW   YORK    POLYCLINIC    MEDICAL    SCHOOL 

AND    HOSPITAL,    VISITING   SURGEON   TO    THE   ALMSHOUSE 

AND    WORKHOUSE   HOSPITALS 


IVITH  EIGHT  COLORED  PLATES  AND 

THREE  HUNDRED  AND    THIRTY-EIGHT  ILLUSTRATIONS 

IN   THE   TEXT 


SECOND   EDITION,   REVISED 


NEW   YORK   AND   LONDON 

D.    APPLETON    AND    COMPANY 

190^ 


Copyright,  1902,  1905 
By  D.  APPLETON   AND   COMPANY 


PRINTED   AT  THE   APPLETON  PRESS 
NEW  YORK,   U.  S.  A. 


PREFACE   TO   SECOND   EDITION 


Three  imprints  of  this  work  having  been  exliausted,  it  is  deemed 
advisable  by  the  publishers  to  issue  a  second  edition.  Since  its  publi- 
cation no  radical  changes  have  taken  place  in  my  opinions  or  practice 
of  rectal  surgery  such  as  would  call  for  a  complete  revision,  but  advan- 
tage is  taken  of  this  opportunity  to  correct  whatever  errors  have  been 
found  in  the  book. 

The  sections  on  Anaesthesia  in  Eectal  Diseases  and  Dysenteric 
Proctitis  have  been  entirely  rewritten;  and  numerous  practical  points 
gained  from  experience  have  been  introduced  into  the  text  throughout 
the  work.  While  I  have  endeavored  to  keep  the  book  abreast  with  the 
times,  its  general  plan  and  scope  remain  unaltered.  To  the  profession 
who  have  so  generously  accepted  the  work,  and  to  the  critics  who  have 
been  so  kind  to  its  shortcomings  and  flattering  in  its  praise,  I  hereby 
extend  my  sincere  thanks. 

James  P.  Tuttle. 


PREFACE 


"WiTHix  the  past  decade  the  field  of  rectal  surgery  has  been  greatly 
broadened  and  its  methods  changed  through  improved  instruments,  asep- 
tic technique,  and  a  wider  knowledge  of  pathology.  The  lively  interest 
taken  by  the  profession  in  this  branch  of  medicine  and  the  little  atten- 
tion paid  to  it  in  the  undergraduate  schools  have  resulted  in  the  estab- 
lishment of  special  clinics  for  teaching  and  treating  rectal  diseases. 

This  book  is  practically  the  outcome  of  twelve  years'  conduct  of  one 
of  the  first  and  largest  clinics  of  this  kind.  The  opinions  expressed 
herein  are  therefore  based  upon  a  clinical  experience  derived  from  a 
large  number  of  actual  cases.  Such  an  experience  teaches  that  no  one 
method  succeeds  always,  and  that  the  practitioner  should  be  conversant 
with  many  in  order  that  he  may  have  resources  in  reserve  for  all  emer- 
gencies. Therefore,  while  relating  my  own  practices  and  opinions,  I 
have  also  given  those  of  other  operators,  so  that  the  reader  may  have  as 
complete  a  knowledge  of  the  subject  as  possible. 

Much  space  has  been  devoted  to  examination,  diagnosis,  and  local 
treatment,  because  these  are  the  subjects  which  the  general  practitioner 
needs  most  to  know.  The  non-operative  treatment  of  each  disease  is 
first  described,  together  with  the  class  of  cases  in  which  it  will  prob- 
abl}'  be  useful;  but  when  such  measures  are  likely  to  prove  futile  I  have 
not  hesitated  to  say  so. 

The  book  has  been  written  during  an  active  practice,  and  almost 
every  opinion  expressed  therein  has  been  put  to  the  test.  I  am  sensible 
of  its  imperfections,  but  should  it  prove  useful  to  the  many  physi- 
cians who  have  honored  me  by  attendance  upon  my  clinics  or  assist  in 
the  dissemination  of  knowledge  upon  these  important  subjects,  I  shall 
be  amply  repaid  for  the  nights  of  labor  it  has  cost. 

I  take  this  opportunity  to  express  my  appreciation  of  the  generous 
assistance  afforded  me  in  the  work  by  Drs.  S.  T.  Armstrong,  George  H. 
"^^'ellbrock,  F.  M.  Jeffries,  Mr.  R.  J.  Hopkins,  and  the  publishers,  who 
have  been  patient,  kind,  and  courteous.  To  them  and  all  the  friends 
who  have  aided  me  by  suggestions  and  encouragement  I  extend  my  sin- 
cere thanks. 

James  P.  Tuttle. 

42  West  Fiftieth  Street,  Xew  York 


co:n'tents 


CHAPTER   I 

EMBRYOLOGY,    AXATOIIY,    AXD    PHYSIOLOGY 

PAGE 

Definitions  of  tlie  parts — Embryology — Anatomy — The  perinseuni — Tschio-rectal 
fossae — The  anal  canal — The  rectum — The  mucous  membrane — Submucous 
layer  —  Muscular  wall  —  Serous  coat — Vascular  supply — Nerve  supply — 
Lymphatics — Retro-rectal  and  superior  pelvi-rectal  spaces — Relations  of 
the  rectum — Sigmoid  flexure  or  pelvic  colon — Physiology      ....     1-46 

CHAPTER  II 

MALFORMATIONS  OF  THE  ANUS  AND  RECTUM 

31  al for  mat  ions  of  the  anus — Entire  absence — Abnormal  narrowing — Partial 
membranous  occlusion — Complete  obstruction  by  a  membranous  diaphragm 
— Anal  opening  at  some  abnormal  point  in  the  perincpum  or  sacral  region — 
2Ialformations  of  the  rectum — Entire  absence — Rectum  arrested  in  its 
descent,  the  anus  being  normal — Rectum  opening  into  some  other  viscus — 
Other  organs,  such  as  the  ureters,  vagina,  or  uterus,  open  into  the  rectum 
— Treatment — Results  of  operations  for  imperforate  anus    ....     47-93 

CHAPTER   III 

EXAMINATION   AND    DIAGNOSIS 

Historical  examination — Digital  examination — Instrumental  examination  of  the 

rectum — Examination  of  fa;ees — Ana?sthesia  in  rectal  diseases  .         .     94-138 

CHAPTER   IV 

CATARRHAL   DISEASES    OF   THE   RECTUM    AND    SIGMOID  :    PROCTITIS   AND    SIGMOIDITIS 

Simple  catarrhal  inflammation — Acute  catarrhal  proctitis — Chronic  proctitis  and 
sigmoiditis  —  Hypertrophic  catarrh  —  Atrophic  catarrh  — Specific  catarrhal 
inflammations — Dysenteric  proctitis  and  sigmoiditis — Diphtheritic  proctitis. 

139-166 " 
CHAPTER   V 

CHRONaC    COLITIS,    MUCOUS    COLITIS,    MEMBRANOUS    COLITIS 

Secondary  membranous  colitis— Ulcerative  colitis — Follicular  colitis     .         .     167-193 

CHAPTER   VI 

TUBERCULOSIS    OF    THE    ANUS,    RECTUM,    AND   PELVIC    COLON 

Perianal  tuberculosis — Miliary  variety — Ulcerative  variety — Anal  lubercidosis — 
Lupoid  ulceration  of  the  anus — Verrucous  ulcerations  of  the  anus — Tubercu- 
losis of  the  rectum  and  sigmoid — Hyperplastic  tuberculosis — Acute  tubercular 
inflammation        ,,,,., 193-213 

Y 


vi  TH?]   ANUS,   RECTUM,   AND   PELVIC   COLON 

CHAPTER  VII 

VENEREAL    DISEASES   OF   THE   ANUS   AND    RECTUM 

PAGE 

Gonorrhoea!  proctitis — Chancroid  of  the  anus — Chancroidal  ulceration  of  tlie 
rectum — Phagedenic  chancroid — Complications — Syphilis — Anal  chancres — 
Rectal  chancres — Secondary  manifestations — Tertiary  lesions — Hereditary  or 
congenital  syphilis  of  the  anus  and  rectum 213-257 

CHAPTER   VIII 

NON-SPECIFIC    ULCERATIONS 

Ulcerations  of  the  perianal  region — Traumatic  ulceration — Herpetic  ulceration — 
Eczema  of  the  anus — Rodent  ulcers — Ulcerations  of  tlie  anal  canal — Simjjle 
ulcers — Traumatic  ulcers — Ulcerations  of  the  rectum  and  sigmoid — Special 
ulcerations — Specific  ulcers — Catarrhal  ulceration — Varicose  ulceration — 
Haemorihoidal  ulcers — Follicular  ulceration — Strictural  ulceration — Carci- 
nomatous ulceration — Ulceration  from  Bright's  disease — Diabetic  ulceration 
— Hepatic  ulceration — Trophic  ulceration — Marasmic  ulceration     .        .     258-290 

CHAPTER  IX 

FISSURE    IN    ANO — IRRITABLE    ULCER — INTOLERABLE    ULCER 

Shape  and  location  of  ulcers — Etiology — Pathology — Symptoms — Reflex  symp- 
toms— Non-operative  treatment — Operative  Treatment — Results  of  dilatation 
— Methods  of  incision — Excision — Submucous  fissure — Complications  of 
fissure  291-318 

CHAPTER  X 

PERIANAL   AND    PERIRECTAL   ABSCESS 

Superficial  abscess — Tegumentary  abscess — Subtegumentary  abscess — Ischio-rectal 
abscess — Profound  abscess — Retro-rectal  abscess — Superior  pelvi-rectal  ab- 
scess— Diffuse  septic  periproctitis — Idiopathic  gangrenous  periproctitis  .     319-352 

CHAPTER  XI 

FISTULA 

Definition— Classification — Frequency — Etiology — Diagnosis — Anatomical  charac- 
ter— Origin — Tubercular  fistula — Operations  in  tubercular  fistula — Prognosis 
— Pathology — Treatment — Non-operative  methods — The  ligature — Fistulot- 
omy— Operative  methods — Instruments  necessary — Incision — Excision— Ex- 
cision with  immediate  suture — Complex  fistula — Primary,  secondary,  and  late 
complications — Incontinence  of  faeces — Treatment  of  incontinence  ,       .    353-420 

CHAPTER   XII 

COMPLICATED    FISTULA 

Fistulas  originating  in  bone  disease— Fistulas  connecting  rectum  with  other 
organs — Urinary  fistula— Recto-vesical  fistula— Recto-urethral  fistula— Rec- 
to-genital fistula  421-454 


CONTENTS  vn 

CHAPTER  XIII 

STRICTURE   OF    THE   RECTUM 

PAGE 

Stricture  of  large  caliber — Congenital  stricture— Neoplastic  stricture — Spasmodic 
stricture — Inflammatory  stricture — DifEuse  inflammatory  stricture — Cicatri- 
cial stricture — Perirectal  stricture — Pathology  of  stricture — Tubercular  stric- 
ture— Syphilitic  stricture — Etiology — Symptoms — Latent  period — Ulcerative 
or  inflammatory  stage — Obstructive  period — Diagnosis — Examination — Ree- 
tometers — Laparotomy  in — Malignant  stricture — Treatment — Dietary  and 
medicinal :  local  and  operative — Gradual  dilatation — Rapid  dilatation  or 
divulsion — Electrolysis,  cauterization,  and  raclage — Proctotomy — Excision — 
Proctoplasty — Lateral  entero-anastomosis — Colotomy — Resume      .        .    455-516 

CHAPTER  XIV 

CONSTIPATION,    OBSTIPATION,   AND   F^CAL   IMPACTION 

Definition — Defecation — Reverse  peristalsis — Etiology — Predisposing  causes — 
Exciting  causes — Local  and  mechanical  causes — The  influence  of  Houston's 
valves — Malformations — Enteroptosis — Acute  flexures — Spasm  of  the  sphinc- 
ter— Extra-intestinal  obstruction — Diagnosis — Acute  constipation — Symp- 
toms— Diagnosis — Treatment — Chronic  constipation — Symptoms — Reflex  and 
constitutional  effects — Mental  and  nervous  symptoms — Treatment — Medic- 
inal, local,  and  operative — Valvotomy — FcBcal  impaction — Symptoms — Diag- 
nosis— Treatment 517-567 

CHAPTER  XV 

PRURITUS    ANI 

Essential  pruritus — Characteristics — Local  causes — Reflex  causes — Constitutional 

causes — Treatment — Constitutional,  local,  and  operative  ....     568-581 

CHAPTER  XVI 

HAEMORRHOIDS — PILES 

Predisposing  causes — Exciting  causes — Nomenclature — Classification — External 
hcemorrhoids — Symptoms — Treatment — Internal  hmmorrhoids — Pathology — 
Symptoms — Preventive  treatment — Palliative  treatment — Operative  treat- 
ment— Dilatation — Cauterization — Electrolysis — Injection  method — Ligature 
— Submucous  ligature — Clamp  and  cautery — Crushing — Excision — Limited 
excision  —  Accidents  and  complications  following  operation  —  Recapitula- 
tion                582-666 


CHAPTER  XVII 

PROLAPSE    OF   THE    RECTUM,    PROCIDENTIA   INTESTINI   RECTI 

Incomplete  prolapse — Etiology — Symptoms — Treatment — Complete  prolapse — 
First  degree — Second  degree — Third  degree — Symptoms — Etiology — Pathol- 
ogy— Treatment — Reduction — Reduction  in  gangrenous  conditions — Cauteri- 
zation— Sigmoidopexy — Rectopexy — Amputation — Complications  of  prolapse 
— Rupture  of  hexmial  sac  in  prolapse 667-710 


viii  THE  ANUS,   RECTUM,   AND  PELVIC  COLON 

CHAPTER  XVIII 

BENIGN   TUMORS   OF   THE    RECTUM 

PAGE 

Connective-tissue  type — Muscular  type — Epithelial  type — Polypus — Seat  and 
manner  of  development — Histology — Course  and  symptoms — Diagnosis — 
Treatment — Fibroma — Enchondroma — Lipoma — Myoma — Lymphadenoma — 
Myxoma — Adeiioma — Simple  adenoma  —  Symptoms — Treatment — Multiple 
adenomata — Etiology — Distribution  of — Conformation — Color — Consistence — 
Condition  of  the  mucous  membrane  in — Symptoms — Diagnosis — Histology — 
Malignant  transformation  in — Treatment —  Villous  tumor :  Fapillo7na — Etiol- 
ogy and  development — Symptoms — Diagnosis — Treatment — Cystoma — Simple 
cysts — Dermoid  cysts — Extra-rectal  dermoids — Postanal  dimples — Sacro-coc- 
cygeal  tumors — Angeioma — Verruca — Fungus  of  the  rectum — Hydatids — 
Hypertrophied  anal  papillce 711-759 

CHAPTER  XIX 

MALIGNANT   NEOPLASMS — CARCINOMA   AND   SARCOMA 

Carcinoma — Seat  of  the  disease — Etiology — Heredity — Age — Sex — Occupation — 
Previous  diseases — Histological  types — Epithelioma — Adenoid  cancer — Medul- 
lary cancer — Scirrhous  cancer — Colloid  cancer — Symptoms — Lines  of  exten- 
sion— Diagnosis — Treatment  in  general — Results — Statistical  tables — Causes 
of  death  following  extirpation — Indications  and  contraindications  to  dif- 
ferent methods  of  treatment — Palliative  treatment — Irrigation — Drugs — 
Curettage — Cauterization — Colostomy — Entero-anastomosis — Sarcoma — Form 
— Number — Characteristics — Site — Course — Histology — Etiology — Symptoms 
— Diagnosis — Treatment — Prognosis 760-809 

CHAPTER   XX 

EXTIRPATION   OF   THE   RECTUM 

Preparation  of  the  patient — Perineal  methods — Sacral  methods — Abdominal 
methods — Combined  methods — Vaginal  method — Prolapse  after — Inconti- 
nence— Stricture — Functional  complications — Conclusions — Choice  of  method 
—Statistical  table 810-858 

CHAPTER  XXI 

COLOSTOMY  -COLOTOMY — ARTIFICIAL   ANUS 

Mortality  from  colostomy — Statistical  table — Lumbar  colostomy — Inguinal  or 
abdominal  colostomy — Temporary  colostomy — Methods  of  fixation  of  the  gut 
— Closure  of  artificial  anus — Permanent  colostomy — Author's  method — 
Colostomy  on  the  right  side 859-893 

CHAPTER  XXII 

FOREIGN  BODIES   IN   THE   RECTUM   AND   SIGMOID   FLEXURE 

Bodies  which  have  been  swallowed — Enteroliths ;  coproliths ;  foecal  stones — 
Bodies  introduced  for  the  relief  of  certain  symptoms — For  purposes  of  con- 
cealment— By  accident  —  Symptoms — Diagnosis — Complications — Prognosis 
—Treatment 894-914 


CONTENTS  ix 


CHAPTER  XXIII 

WOUNDS,   INJURIES,   AND   RUPTURE   OB"   THE   RECTUM 

PAGE 

Characters  of — Causes  of  —  Prognosis  —  Symptoms  —  Mortality  from — Treat- 
ment             ,        .    915-921 

CHAPTER  XXIV 

NERVOUS   OR   HYSTERICAL   RECTUM 

Insane  rectum — Neuralgia  of  the  rectum — Irritable  rectum — Morbid  sensibility 
of  the  rectum — Reflex  irritation — Nerve  affections — Rheumatism  and  gout  in 
— Insensitive  rectum — Treatment 923-929 

CHAPTER  XXV 

RECTO-COLONIC   ALIMENTATION 

History  of — Indications  for — Principles  and  methods — Selection  of  materials  in — 
Methods  of  administering — Formulae 930-937 

Index ,    939-961 


LIST   OF  ILLUSTKATIONS 


1.  Development  of  intestinal  tract  (Schaifer)       .......  2 

2.  Development  of  rectum  (Schaffer) 3 

3.  Divisions  of  anal  canal  (Stroud) 4 

4.  Divisions  of  the  pelvic  outlet 5 

5.  Dissection  showing  muscular  aiTangement  at  pelvic  outlet,  perineal  triangu- 

lar spaces,  and  ischio-reetal  fossae          . 6 

6.  ^Normal  anus  in  repose 8 

7.  The  anal  canal 9 

8.  Longitudinal  section  of  anal  walls,  showing  arrangement  of  muscular  fibers  10 

9.  Female  perinaeum  (Kelly) 11 

10.  Levator  ani  muscle 12 

11.  Levator  ani  muscle  (Cripps) 13 

12.  Cast  of  rectum  (Quenu  and  Hartmann)     .         .        .        .        .        .         .        .  16 

13.  Cast  of  rectum  (Quenu  and  Hartmann) 16 

14.  Cast  of  rectum  and  anal  canal  (Quenu  and  Hartmann) 16 

15.  Cast  of  rectum  and  lower  loop  of  sigmoid  (Martin) 16 

16.  Cast  of  rectum  (Quenu  and  Hartmann) 17 

17.  Cast  of  rectum  and  anal  canal  (Quenu  and  Hartmann) 17 

18.  Arrangement  of  circular  muscular  fibers  of  rectum 19 

19.  Diagrammatic  illustration  of  chief  aggregations  of  circular  muscular  fibers 

in  rectal  wall 19 

20.  Dissection  by  jMartin,  showing  fan-shaped  arrangement  of  circular  muscular 

fibers 21 

21.  Arrangement  of  longitudinal  muscular  layer  of  the  rectum  (Lamier)     .         .  22 

22.  Showing  reflection  of  peritonaeum  from  rectum  on  to  the  pelvic  walls  .        .  23 

23.  Illustrating  usual  location  of  Houston's  valves 25 

24.  Inferior  and  middle  valves  of  Houston 27 

25.  Abnormal  development  of  valves  of  Houston 28 

26.  Inferior  mesenteric  artery  giving  off  sigmoidal  branch  and  terminating  in 

superior  haemorrhoidal 29 

27.  External  and  middle  haemorrhoidal  veins  arising  from  the  anal  canal  and 

lower  end  of  the  rectum  ;  also  branches  running  upward  to  form  superior 

hasmorrhoidal  veins 31 

28.  Vascular  supply  of  lower  end  of  rectum  (partly  schematic)    ....  32 

29.  Spinal  nerves  of  the  rectum  and  anus 34 

30.  Lymphatics  of  anal  and  perianal  region 35 

31.  Showing  connection  between  perianal  and  inguinal  lymphatics     ...        .35 

32.  Exaggerated  retro-rectal  cellular  space 37 

33.  Line  of  attachment  of  the  mesosigmoid 41 

34.  Intersigmoid  fossa,  showing  left  sigmoidal  artery    ......  43 

35.  Complete  absence  of  the  anus 50 

xi 


xii  Till-;  ANLs.  ufaM'im.  and  rKl.VR-  rOl.ON 

FUJrRK  PAGF 

;^6.     Moinbranous  cxvlusion  of  tho  ami? 5^ 

87.     Partial  inombranous  iHvlusion  of  tho  amis 5-4 

38.  Anus  ojHMiiiijj  at  tip  of  oocoyx oC 

39.  Comploto  absoneo  of  tho  reotum.  tho  colon  oiuliiig  in  a  larg\>  dilatation  and 

tho  anus  Knng  normal 5T 

40.  Csso  in  which  rtKMum  faiWi  to  reach  tho  anus 58 

41.  C*so  in  which  tho  reotun\  do^cendtnl  posterior  to  anal  canal  ....  58 

42.  Fibrous  cord  loadinsi  from  tho  anus  to  tho  arrei^tod  rectum    .        .        .        .59 

43.  Ro<.Hum  dosconding  pi>storior  to  tho  anus  and  tho  latter  opening  into  tho 

vagina  (Amussat) t>'^ 

44.  Atresia  ani  vodcHlis t>» 

45.  Atresia  .ini  urethralis t>4 

46.  Atresia  ani  preputi.ilis 65 

47.  Atresia  ani  \'aginalis t»t> 

48.  Malformation  in  which  tho  i>eriionoal  cul-de-^ic  extends  Umwoou  ilio  blind 

ends  of  the  ret'tum  and  anus 'i> 

40.     Commtxle  for  otTice  use 5^9 

50.  Loft  lateral  or  Sims's  posture 100 

51.  Exaggeratoti  lithotomy  jKvsition 101 

52.  Ii\correot  kneo-c^host  {wsture 102 

53.  Correct  knee-chost  jx^sture H^^ 

54.  Patient  hold  in  kniNM'hest  ix>sture  by  straj^s  and  Iwnds U>;> 

55.  Pationt  hold  in  knee-i'host  i>osture  on  Martin  ciiair 104 

56.  The  Little  ofliee-lounge  closo<i 105 

57.  Electric  he^d-light 113 

58.  Kels«y"s  rectal  sixvulum 114 

59.  Conical  bivalve  rectal  s[>eculum 114 

60.  Gant's  oj>erating  n^ctal  stKX'ulum 115 

61.  Sims's  rectal  si>eculum 115 

62.  O'XeiU's  rectal  sjxvulum 115 

63.  Authors  eoniciil  fenestrated  sj>eculum 115 

64.  Van  Buron's  rectal  si>etMilum 116 

65.  Pnut's  rectal  retractor 116 

66.  Mathews's  rectal  sj>eculum 117 

67.  Kelly's  proctt>sco}>e 117 

68.  Kelly's  set  of  instruments  for  ejcamining  the  recuuu  and  sigmoid  .119 

69.  Kelly's  ivctal  curette 120 

7t>.     Kelly's  iv^tal  so*wp 120 

71.  Kelly's  sphinctex  dilator 120 

72.  Tiittle's  modification  of  Kelly's  sigmoidoscope        .....  121 
7S.    I^ws's  pneumatic  proctosco{>e 123 

74.  I^ws's  proctoscoi>e  with  aj^ertiire  in  window  for  tiieiapeutic  applications    .  122 

75.  Tuttle's  pneumatic  pnvtosoope 133 

7S.  Tuttle's  long  sigmoidost^ijv  with  flexible  obturator  giving  the  instrnment 

the  Mereier  curve 124 

77.  Tuttle's  silver  priil>e 126 

78.  Tuttle's  rectal  s[xx>n 126 

79.  Tnttle's  dressing-forcej^s 127 

80.  Alligator  forcej^s  for  use  through  proctoscope 127 

81.  Wales's  soft-ruV>ber  rectal  Iwugie 128 

82.  Rectal  bougie  a  Iwule 129 

8;^.    Tuttle's  iwtal  irrisrator 144 


a  parient  with 
(Delafield  and 


LIST  OF  ILLUSTRATIONS  xm 


84-    Hypertrophic  catarrhal  proctitis:  specimen  showing  increase  in  depth  of 

tubules  and  intertubtilar  substance 147 

85.  Atrophic  catarrhal  proctitis :  specimen  showing  atrophy  and  exfoliation  of 

epithelial  cells  and  decrease  in  intertubular  substance 
85a.    Typical  ulcers  of  amcebie  dysentery     .... 

86.  Linear  and  stellate  ulcerations  on  Houston's  valves  seen  in 

amoebic  dysentery         .        .        .        . 

87.  Transverse  section  of  inflamed  follicle   . 

88.  Gross  appearance  of  mucous  membrane  in  follicular  colitis 

Pruden;      

88  A.    First  tier  of  sutures  in  valvular  colostomy  (Gibson) 

88  B.    Last  tier  of  sutures  in  Gibson's  method 

88  C.    Longitudinal  section  showing  results  of  infolding  by  Gibson's  method 

89.  Perianal  tubercular  ulcer  surrounding  external  opening  of  a  fistula    . 

90.  Tubercular  ulceration  of  the  rectum  with  submucous  fistula 

91.  Transverse  section  of  tubercular  ulcer  of  the  rectum,  showing  elevated  cen- 

ter and  undermined  edges 

92.  Tubercular  ulcer  of  the  rectum 

98.     Tubercular  ulceration  of  the  rectum 

04.     Tubercular  ulcer  encircling  the  sigmoid 

Oo.     Tubercular  stricture  and  ulceration  of  the  sigmoid      .... 

96.  Photomicrograph  of  tubercular  ulcer  of  the  rectum      .... 

97.  Tubercular  ulcer  with  spud  introduced  beneath  the  undermined  edge 

98.  Multiple  perianal  chancroids  .... 
09.     Photomicrograph  of  gumma  from  the  rectum 

100.  Impacted  fseces  in  cavity  of  follicular  ulcer   . 

101.  Fissure  in  ano 

102.  Irregular  fissure  or  irritable  ulcer  of  anus 

103.  Fissure  with  sentinel  pile  in  syphilitic  child  . 

104.  Fissure  produced  by  rent  in  a  crypt  of  Morgagni 

105.  Perineuritis  in  chronic  fissure  (Qnenu  and  Hartmann) 
100.     Intrafascicular  neuritis  in  chronic  fissure  (Quenu  and  Hartmann) 

107.  Eversion  of  anterior  fissure  by  finger  in  the  vagina 

108.  V-shaped  incision  for  fissure  at  the  posterior  commissure  of  the  anu; 

109.  Intramural  or  submucous  abscess  of  the  rectum    .... 

110.  J^,  ischio-rectal  abscess ;  ^,  superior  pelvi-rectal  abscess 

111.  Bilateral  ischio-rectal  abscess  opening  into  rectum  posteriorly     . 

112.  Ischio-rectal  and  retro-rectal  abscesses  communicating  with  each  other. 

The  rectum  is  dissected  off  and  drawn  forward 

113.  Ischio-rectal  and  submucous  abscesses  communicating 

114.  Ischio-rectal  and   submucous   abscesses   connected  by  tract  through  the 

muscles 

115.  Retro-rectal  abscess 

116.  Blind  external  fistulas 

117.  Blind  internal  fistulas.     A.  subtegumentary ;  5,  subaponeurotic 

118.  Complete  subaponeurotic  fistulas,  showing  irregular  tracts  . 

119.  Subtegumentary  fistulas.     A,  blind  external ;  B,  complete  . 

120.  External  opening  of  subtegumentary  fistula 

121.  Subtegumentary  fistula  almost  surroimding  the  anus   . 

122.  Straight   tubular    fistula    passing    directly   through   external    sphincter. 

Drawn  from  post-mortem  dissection 

123.  Tract  of  urinary  fistula  which  simulated  the  ano-rectal  variety 

124.  Outline  of  tortuous  ano-rectal  fistula 


xiv  THE  ANUS,   RECTUM,  AND   PELVIC   COLON 

FIGl-RE  PAGE 

125.  Transverse  section  of  tubercular  fistula  (photomicrograph)  .                 ,         .  375 

126.  Allingham's  ligature-carrier 380 

127.  Ligature  passed  through  fistula  and  secured 381 

128.  Fistula  in  which  the  internal  opening  (A)  is  in  a  different  quadrant  from 

that  in  which  the  abscess  cavity  {B)  is  nearest  the  rectal  wall,  and  show- 
ing how  perforating  the  wall  at  the  latter  point  and  incising  the  gut 
down  to  the  anus  by  ligature  or  knife  will  leave  a  part  of  the  pathological 

tract  untouched 383 

129.  Mathews's  fistulotome 384 

130.  Clover's  crutch 386 

131.  Brodie's  probe-pointed  grooved  director 387 

132.  Artery  forceps 387 

133.  T-shaped  haemostatic  forceps 387 

134.  Needles  for  rectal  surgery  (actual  size) 388 

135.  Wyeth's  needle-holder 388 

136.  Grooved  director  passed  through  fistulous  tract  and  showing  how  passing 

a  bistoury  along  the  groove  and  cutting  outward  will  divide  the  sphinc- 
ter obliquely 389 

137.  Fistula  laid  open  outside  of  sphincter  so  that  the  latter  can  be  cut  squarely 

across 390 

138.  First  step  in  excision  of  fistula 393 

139.  Removal  of  a  fistula  threaded  upon  a  probe 393 

140.  Method  of  introducing  the  sutures  after  excision  of  fistula  ....  394 

141.  Final  step  in  closing  fistula 395 

142.  Rectal  portion  of  fistula  closed  by  flap  of  mucous  membrane       .         .         .  396 

143.  Y-shaped  blind  internal  fistula 399 

144.  Director  passing  through  internal  and  external  openings  of  fistula  and 

leaving  part  of  tract  untouched 400 

145.  Fistulous  tract  passing  through  external  sphincter 401 

146.  Subtegumentary  fistula  involving  ischio-rectal  and  retro-rectal  spaces        .  402 

147.  Long  fistulous  tract  opening  near  the  greater  trochanter     ....  403 

148.  Tract  of  horseshoe  fistula  operated  on  in  September,  1901    ....  405 

149.  Dumb-bell  fistula ■ 406 

150.  Results  of  operation  in  preceding  case 406 

151.  1.  Oblique  incision  of  sphincter,  which  is  frequently  followed  by  inconti- 

nence.    2.  Transverse  incision  not  likely  to  result  in  same       .        .        .  413 

152.  On  the  left  is  shown  the  separation  and  lengthening  of  the  muscle  (1  to  2), 

due  to  oblique  incision.  On  the  riglit  is  seen  the  vicious  union  of  the 
fibers  and  the  line  of  incision  for  repairing  the  muscle      .         .        .        .414 

153.  Old  method  of  repairing  sphincter 415 

154.  Chetwood's  operation  for  faecal  incontinence — first  step        ....  417 

155.  Chetwood's  operation — second  step 418 

156.  Recto-urethral  fistula.     1.  Tract  running  downward  and  backward,  prob- 

ably originating  in  urethra.     2.  Tract  running  downward  and  forward, 

probably  originating  in  rectum 426 

157.  Rectum,  perinaeum,  and  urethra  incised  to  expose  recto-urethral  fistula      .  434 

158.  Recto-urethral  fistula  and  wound  in  the  rectum  closed.     The  incision  in 

the  urethra  anterior  to  the  fistula  is  left  open 435 

159.  Final  step  in  operation  for  recto-urethral  fistula 436 

160.  Resection  of  the  urethra  for  recto-urethral  fistula 437 

161.  Recto-vesico-vaginal  fistula.     The  fistulous  tract  indicated  by  the  dotted 

line  passed  around  the  cervix  and  not  through  it       ....        .  440 


LIST   OP   ILLUSTRATIONS  XV 

FIGURE  PAGE 

162.  Lauenstein's  operation  for  recto-vaginal  fistula 452 

163.  Closure  of  recto-vaginal  fistula,  showing  mucous  flap  brought  outside  of 

rectum  and  sutured  to  the  skin 453 

164.  Longitudinal  section  of  stricture  of  the  rectum     ......  464 

165.  Stricture  of  the  rectum  due  to  prostatic  inflammation.     A,  perforation  of 

the  rectum ;  B,  cavity  in  which  lemon-seeds  were  found ;  C,  inflamma- 
tory hyperplasia ;  D,  peritonaeum 467 

166.  Stricture  complicated  by  recto- vaginal  fistula        ......  474 

167.  Stricture  of  the  rectum  causing  procidentia ,  484 

168.  Bougie  arrested  in  diverticulum  surrounding  a  stricture      ....  489 

169.  Bodenhamer's  bulbous  rectal  bougie 490 

170.  Crede's  rectal  bougie 496 

171.  Sims's  rectal  dilator 499 

172.  Durham's  rectal  dilator 500 

173.  Multiple  stricture  of  the  rectum 505 

174.  Trocar   for   insertion  of  female  segment  of  Murphy  button  in  Bacon's 

operation  for  stricture  of  the  rectum 510 

175.  Lateral  entero-anastomosis  (Bacon).     A,  mesoreetuni 511 

176.  Clamp  introduced  through  stricture  and  anastomotic  opening  in  order  to 

widen  the  caliber  of  the  gut  in  Bacon's  operation 512 

177.  Diagrammatic  illustration  of  acute  flexure  between  the  sigmoid  and  rec- 

tum          523 

178.  Malformation  of  the  sigmoid  flexure 536 

179.  Acute  flexure  of  the  sigmoid  on  the  rectum 537 

180.  Adhesion  of  sigmoid  to  the  rectum,  causing  acute  flexure  at  their  junction  538 

181.  Inflammatory  adhesion  of  the  appendix,  binding  the  sigmoid  to  the  ante- 

rior surface  of  the  sacrum  and  preventing  its  rising  out  of  the  pelvic 

cavity 539 

182.  Rectal  electrode .  555 

183.  Testing  resistance  of  valve  with  Martin  Hook  (Hemmeter)  ....  558 
184     Fixation  and  incision  of  valve  after  Martin's  method  (Hemmeter)       .         .  559 

185.  Martin's  knives 560 

186.  Pennington  clip  for  cutting  rectal  valves  and  the  instrument  for  apply- 

ing it     560 

187.  Pennington  clip  applied  .        '. •  561 

188.  Gant's  clip  for  cutting  rectal  valves        . 561 

189.  Rectal  valve  after  incision  by  Martin's  method  (Hemmeter)          .        .        .  562 

190.  Rectal  valve  after  operation  by  Pennington's  clip 562 

191.  Kelsey's  rectal  scoop 565 

192.  Pruritus  ani 570 

193.  Prolapsed  internal  hjemorrhoid  with  condyloma  attached     ....  606 
194     Mixed  hsemorrhoid 611 

195.  Hard-rubber  pile-pipe 616 

196.  Mathews's  rectal  divulsor 619 

197.  Gant's  syringe  for  injecting  hai'morrhoids 628 

198.  Transfixion  and  ligature  of  htemorrhoid 632 

199.  Ligation  of  hemorrhoid  after  Allingham's  method 633 

300.     Subcutaneous  ligature  of  a  hfemorrhoid 636 

201.  Tuttle's  hipmorrhoidal  forceps 638 

202.  Pile  seized  with  haemorrhoidal  forceps 638 

203.  Method  of  applying  the  clamp  after  the  ha?morrhoid  is  dragged  down        .  639 

204.  Gant's  haemorrhoidal  clamp 640 


Xvi  THE   ANUS,   RECTUM,  AND   PELVIC  COLON 

FIGVRE  PAGE 

205.  Ha?morrhoidal  clamp 640 

206.  Modified  Paquelin  cautery  (Kennedy's) 6'41 

207.  Groove  cut  into  rauco-cutaneous  tissue  into  which  the  clamp  fits        .         .  642 

208.  Stump  of  excised  hiemorrhoid  held  by  clamp 643 

209.  Allingham's  ha?morrhoid  crusher 646 

210.  Allingham's  forceps  for  use  in  crushing  openition 647 

211.  Smith's  hfemorrhoid  crusher 647 

212.  First  step  in  modified  Whitehead  operation  for  haemorrhoids       .         .        .  650 

213.  Second  step  in  modified  Whitehead  operation 651 

214.  Third  step  in  modified  Whitehead  operation 652 

215.  Modified  Whitehead  operation  completed 653 

216.  Earle's  forceps 655 

217.  Earle's  operation 655 

218.  Limited  excision  of  haemorrhoids 656 

219.  Exstrophy  of  mucous  membrane  following  faulty  Whitehead  operation      .  657 

220.  Strangulated  hipraorrhoids 659 

221.  Incomplete  prolapse  of  the  rectum 668 

222.  Complete  procidentia  recti — first  degree 672 

223.  Complete  procidentia  recti — second  degree 672 

224.  Complete  procidentia  recti — third  degree 673 

225.  Complete  prolapse  of  the  rectum,  showing  circular  arrangement  of  the  rugic.  674 

226.  Rectal  hernia  or  archocele 676 

227.  Delorme's  operation  for  procidentia  recti 688 

228.  Delorme's  operation  completed,  showing  reduplication  of  rectal  wall  .        .  689 

229.  Infolding  of  the  gut  in  Peters's  operation  for  procidentia  recti    .         .         .  690 

230.  Attachment  of  the  gut  to  the  abdominal  wall  in  Peters's  operation      .         .  690 
281.     Rectopexy  for  procidentia  recti — the  incision 691 

232.  Rectopexy — the  gut  inverted  and  brought  through  the  incision  ;  the  su- 

tures passed  through  its  muscular  walls 692 

233.  Rectopexy — the  sutures  out  through  the  tissues  on  each  side  of  the  sacrum  693 

234.  Rectopexy — the  operation  completed 694 

235.  Rectal  hernia  protruding  through  the  anus 706 

236.  Rectal  hernia,  same  case  as  Fig.  235,  protruding  through  vagina  .         .  707 

237.  Myxoma,  rectal  polyp 713 

238.  Ladinski's  rectal  snare 715 

239.  Fibroids  of  the  anus  and  rectum.     Drawn  from  photograph  taken  before 

operation,  1894.     Nine  distinct  tumors  were  removed        ....  716 

240.  Myxoma  (Stengel) 722 

241.  Multiple  adenomata  of  the  rectum 728 

242.  Hypertrophic  folliculitis  of  rectum  and  colon  (Lilienthal's  case)  .        .        .  729 

243.  Lympho-adenoma 733 

244.  Papilloma  with  cylindrical  epithelioma  (Quenu  and  Hartmann)  .        .        .  739 

245.  Schematic  illustration  of  rectal  papilloma 740 

246.  Papilloma  of  rectum 741 

247.  Villous  polyp  of  the  rectum  (Ball) 744 

247  A.     Congenital  postanal  fissure.    247  B.  Congenital  postanal  dimple.    (Mar- 

koe  and  Schley.  Am.  Jour,  of  Med.  Sci..  May.  1902)        ....  752 

248.  Hypertrophied  anal  papillae 759 

249.  Epithelioma 767 

250.  Adenoid  cancer 768 

251."    Medullary  cancer 769 

252.     Scirrhns  of  intestine 770 


LIST   OF   ILLUSTRATIOXS  xvii 

FIGURE  PAGE 

353.     Colloid  cancer  of  large  intestine      .        .         .        .        .        =         .        .        .  771 

254.  Rectal  specimen  forceps 773 

255.  Medullary  carcinoma  of  the  rectum 775 

256.  Scissors  employed  for  obtaining  specimens  of  rectal  growths        .         .        .  781 

257.  Lateral  entero-anastomosis 797 

258.  Entero-anastomosis  with  complete  elimination  of  the  fascal  current  from 

the  diseased  area 798 

259.  Anastomosis  of  the  ileum  with  the  rectum  for  carcinoma  of  the  sigmoid 

and  ileum 799 

260.  Round-  and  spindle-celled  sarcoma 803 

261.  Melanotic  alveolar  sarcoma 804 

262.  Line  of  incision  in  perineal  proctectomy  by  Allingham's  method          .         .  815 
263      Second  step  in  Allingham's  method  (Mathews)       .                 ....  816 

264.  Perineal  extirpation  of  the  rectum  (Quenu's  method) 816 

265.  Perineal  extirpation — loosening  rectum  from  anterior  perineal  rhaphe        .  817 

266.  Perineal  extirpation 818 

267.  Perineal  extirpation — the  peritoneal  pouch  laid  open 819 

268.  Perineal  extirpation 820 

269.  Perineal  extirpation  completed 821 

270.  Kraske's 823 

271.  Hochenegg's 823 

272.  Bardenheuer's 823 

273.  Rose's 823 

274.  Von  Heineclie's 823 

275.  Levy's 826 

276.  Rydygier's 823 

277.  Hegar"s 823 

278.  Extirpation  of  the  rectum  by  the  sacral  route — first  step  in  the  bone-flap 

operation       .,....,.._...  824 

279.  Sacnim  removed    to    expose    rectum    and    other    pelvic   organs  (partly 

.  schematic) 825 

280.  Second  step  in  bone-flap  operation  .        . 826 

281.  Third  step  in  bone-flap  operation 827 

282.  Fourth  step  in  bone-flap  operation 828 

283.  Fifth  step  in  bone-flap  operation.     The  growth  has  been  resected  and  the 

ends  of  the  intestine  have  been  sutured  together 829 

284.  Sacral  anus,  made  in  bone-flap  operation  when  it  was  impossible  to  estab- 

lish aperture  in  normal  position •        .        .  830 

285.  Final  step  in  bone-flap  operation 831 

286.  Rectal  carcinoma  involving  vaginal  wall 832  ■ 

287.  Incision  in  vaginal  extirpation  (Murphy) 833 

288.  Separation  of  rectum  from  vaginal  walls  (Murphy) 834 

289.  Rectum  laid  open  and  cut  across  below  neoplasm  (Murphy)          .         .        .  835 

290.  Resection  of  involved  area  in  vaginal  extirpation  of  the  rectum  (Murphy)  .  836 

291.  Restoration  of  gut  in  vaginal  extirpation  of  the  rectum  (Murphy)        .        .  837 

292.  Closure  of  peritoneum  and  vaginal  wound  after  vaginal  extirpation  of  the 

rectum  (Murphy) 838 

293.  Colorectostomy  (Kelly)   or   invagination  of   colon   through  a  slit   in   the 

anterior  wall  of  the  rectum 839 

294.  Method  of  widening  the  caliber  of  the  gut  after  colorectostomy  .         .         .  840 

295.  Result  of  colorectostomy  for  carcinoma  as  seen  through  proctoscope  five 

years  after  operation 841 


XVUl 


THE   ANUS,   RECTUM,   AXD   PELVIC  COLON 


sulurcs  in 


FIGURE 

296.     Abdomino-anal  extirpation  of  liigh  rectal  cancer — enucleation  of  diseased 

portion  through  abdominal  route 

Abdomino-anal  extirpation.      Sigmoid  is  In-oiight  down  Ihrougii  everted 

rectum  and  sutured  after  method  of  Weir  ...... 

Final  steps  in  abdomino-anal  extirpation.     Peritoneal  cavity  closed,  intes 

tinal  tract  restored,  and  drainage-tube  fixed  in  retro-rectal  space 
Exposure  of  ha^morrhoidal  and  sigmoidal  artery  in  abdominal  extirpation 

of  the  rectum 

Line  of  incision  in  lumbar  colostomy      ..... 

Lumbar  colostomy 

Lumbar  colostomy  completed 

Lieision  in  inguinal  colostomy 

Inguinal  colostomy 

Inguinal  colostomy,  Cripps's  method 

Inguinal  colostomy,  Cripps's  method.     Final  sutures  in  jjlace 
Cross-section  after  colostomy  by  Allingham's  method    . 
Cross-section  after  colostomy  by  Kelsey's  method  . 

Inguinal  colostomy,  Bodi tie's  method 

Enterotomy  after  colostomy  by  Bodine's  metiiod  . 
Inguinal  colostomy  (Mathews's  method)         .... 
Cross-section  after  colostomy  by  Maydl-Reclus  method 

Temporary  inguinal  colostomy 

Temporary  inguinal   colostomy.      Gut  supported  on  rod   and 

position 

Incision  for  opening  the  gut  in  temporary  inguinal  eoloslomy 

Dupuytren's  enterotome 

Nelaton's  intestinal  clamp 

Collins's  long  clamp  forceps 

Murphy  button  open 

319a.  Murphy  button  closed 

320.     Senn's  decalcified  bone-plate   . 

Laplace's  forceps  for  intestinal  resection        .... 

O'Hara's  clamps 

Isolation  of  diseased  portion  of  gut  by  O'llara's  method 
Diseased   portion   excised   and   edges  of    peritonaeum    brought 

(O'Hara) 

Sutures  introduced  over  forceps  (O'Hara)       .... 

Sutures  tied  and  forceps  ready  to  be  withdrawn  (O'Hara)     . 

Gut  seized  for  lateral  entero-anastomosis,  by  O'Hara's  method 

Lateral  entero-anastomosis  (second  step  in  O'Hara's  method) 

Lateral  entero-anastomosis  completed  (O'Hara's  method) 

Closure  of  artificial  anus  by  plastic  method   .... 

Closure  of  artificial  anus  by  plastic  method  completed  . 

Cross-section  after  extra-peritoneal  closure  of  artificial  anus 

Ligature  thrown  around  proximal  loop  of  gut  in  colostomy  in  order  to 

secure  fjecal  control 

Witzel's  method  of  colostomy 

Bailey's  method  of  permanent  colostomy 
Braun's  method  of  permanent  colostomy  (Bryant) 
Weir's  method  of  permanent  colostomy  (Bryant)   . 
Permanent  colostomy  (author's  method) 
Permanent  colostomy  completed  by  author's  method 


297. 

298. 

299. 

300. 
301. 
302. 
303. 
304. 
305. 
306. 
307. 
308. 
309. 
310. 
311. 
312. 
313. 
314. 

315. 
316. 
317. 
318. 
319. 


321. 
322. 
323. 
324. 

325. 
326. 
327. 
328. 
329. 
330. 
331. 
332. 
333. 

334. 
335. 
336. 
337. 
338. 
339. 


together 


843 


844 


845 


LIST   OF   COLORED   PLATES 


PLATE  I. — Inflammatory  Diseases     .        .        .        .        , 
1.     Xormal  Mucous  Membrane. 
3.    Acute  Catarrhal  Proctitis. 

3.  Atrophic  Catarrhal  Proctitis. 

4.  Hypertrophic  Catarrhal  Proctitis. 

5.  Follicular  Proctitis. 

6.  Ulcerative  Proctitis. 

PLATE   II.— Anal  Tuberculosis  ...... 

1.  Tubei'cular  Ulceration  with  Fistula. 

2.  Lupoid  Ulcer. 

3.  Supei-ficial  Tubercular  Ulceration. 

PLATE  III. — Syphilitic  Affections  of  the  Rectum 

1.  Mucous  Patch  on  Houston's  Fold. 

2.  Syphilitic  Stricture  (seen  through  proctoscope). 

3.  Hereditary  Syphilitic  Fissure. 


FACING 
PAGE 

.    140 


198 


253 


594 


PLATE   IV.— Hemorrhoids 

1.  Thrombotic  Ha?morrhoids. 

2.  Inflamed  Hjpmorrhoids  with  Erosion. 

3.  Internal  Haemorrhoids  with  CEdema  of  Anal  Margin. 

4.  Prolapsing  Internal  Hpemorrhoids. 

PLATE  Y. — Condyloma,  Fibroid,  and  Papilloma     .        .        ■ .      »        •        =    "^38 

1.  Condylomata  Lata. 

2.  Fibroid  Polypus. 

3.  Papilloma. 

PLATE   VI.— Malignant  Neoplasms    .        .        .        , 802 

1.  Melano-sarcoma. 

2.  Epithelioma  of  Anus  and  Vulva. 

PLATE  VII. — Proctoscopic  Appearance  and  Specimen  of  Medullary  Car- 
cinoma         804 


PLATE  VIIL— Malignant  Neoplasms 


806 


Ulcerative  Medullary  Carcinoma. 
Epithelioma  of  Sigmoid. 
Epithelioma  of  Sigmoid  (proctoscopic). 
Epithelioma  with  L'lceration  (proctoscopic). 


DISEASES    OF   THE 
ANUS,   RECTUM,   AND   PELYIC   COLON 


CHAPTER    I 
E3IBRY0L0GY,   ANATOMF,   AND  PHYSIOLOaT 

For  the  purjjoses  of  our  discussion  the  following  anatomical  divi- 
sions Avill  be  observed : 

The  anus  is  that  portion  of  the  intestinal  tract  which  extends  from 
the  margin  of  the  true  skin  to  the  free  borders  of  the  semilunar  valves 
of  Morgagni. 

The  rectum  is  that  portion  of  the  intestinal  tract  which  extends  from 
the  free  borders  of  the  semilunar  valves  to  a  point  about  opposite  the 
third  sacral  vertebra,  where  the  gut  becomes  entirely  surrounded  by 
peritongeum  and  the  lower  end  of  the  mesentery  is  attached. 

The  'pehic  colon  or  sigmoid  flexure  is  that  portion  of  the  intestinal 
tract  which  extends  from  the  third  sacral  vertebra  to  the  lower  end  of 
the  descending  colon  at  the  external  border  of  the  left  psoas  muscle. 

This  division  differs  from  that  ordinarily  given  in  works  on  anatomy 
and  text-books  on  diseases  of  the  rectum,  but  it  gives  definite  limits  to 
all  three  portions,  and  confines  the  term  rectum  to  the  immobile  por- 
tion of  the  canal  comprised  between  the  points  where  the  mesentery 
ceases  above  and  the  mucous  membrane  ceases  below. 

Embryology. — The  sigmoid  and  rectum,  like  the  upper  portion  of 
the  alimentary  canal,  are  developed  from  the  hypoblast  and  mesoblast 
of  the  ovum;  the  anus  is  developed  from  the  epiblast.  In  the  develop- 
ment of  the  embryo,  after  the  formation  of  the  neural  canal  and  the 
folding  in  of  the  three  layers  of  the  blastoderm,  which  forms  the  head 
and  produces  a  cavity  known  as  the  "  foregut,"  there  appears  a  pro- 
trusion at  the  posterior  blind  end  of  the  enteric  groove,  creating  the 
so-called  "hindgut,"  or  rudimentary  rectum. 

Soon  after  the  formation  of  the  neural  canal,  the  mesoblast  .is 
divided  by  cleavage  into  two  layers,  one  of  which  follows  the  hypoblast 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


and  the  otlier  the  epiblast,  and  the  space  between  them  gra anally  en- 
larges to  form  the  coelum  or  pleuro-peritoneal  cavity. 

From  tlie  hypoblast  the  mucons  membrane,  and  probably  the  sub- 
mucons  tissue  develop,  while  the  inner  layer  of  the  mesoblast  forms  the 
muscular,  peritoneal,  and  glandular  portions  of  the  gut  (SchafEer). 

To  the  sixth  week  of  gestation  the  large  and  small  intestines  are 
one  cavity,  and  of  nearly  an  uniform  caliber,  with  the  exception  of  the 

lower  portion  of  the  hindgut,  which 
even  at  this  early  period  is  more  ca- 
pacious than  any  other  portion  of 
the  intestinal  tract  except  the  stom- 
ach. About  the  sixth  week  the 
vermiform  appendix  is  developed; 
from  this  time  the  colon,  sigmoid, 
and  rectum  grow  more  rapidly  in 
circumference  than  the  "  foregut," 
or  small  intestine,  and,  extending 
downward,  more  and  more  nearly 
approach  the  outer  layer  of  the 
mesoblast  and  the  epiblast  at  the 
lower  portion  of  the  embryo 
(Fig.  1). 

The  blind  end  of  the  hindgut, 
in  close  apposition  with  the  lower 
end  of  the  spinal  column  and  orig- 
inally connected  with  the  neurenter- 
ic  canal,  forms  what  has  been  called 
the  cloaca,  in  that  it  receives  at  this 
period  through  the  allantois  the  se- 
cretions of  the  urinary  and  genital 
organs  as  well  as  those  of  the  in- 


FlG.    1. 


-Development  of  Intestinal 
Tract  (Schaffer). 
o,  notochord ;  6,  hypophysis ;  c,  bile-duct ;  d, 
tongue ;  e,  permanent  kidney ;  /,  cloaca ;  . 

g,  anus;  h,  sexual  prominence;  i,  tail;  j,     LGSlinai    Canai. 

caecum  coli ;  k,  trachea  ;  I,  larynx ;  m,  pan-  About  the  eighth  week  of  gCSta- 

creas;  «,   section   of  mandibular  arch ;  o,     ^-^^^    ^j^g    ^^^^^.^    -g    divided,    hoW    We 
commencing  lung ;  p,  stomach. 

do  not  clearly  understand,  into  two 
parts;  the  anterior  forms  the  uro-genital  organs  and  the  posterior  the 
enteron  or  rudimentary  rectum.  Imperfection  in  this  division  causes 
many  of  the  abnormalities  of  the  rectum. 

The  urinary  and  generative  organs  develop  from  the  inner  layer  of 
the  mesoblastj  some  of  the  cells  from  which  differentiate  into  a  cord 
in  which  a  lumen  is  formed,  the  so-called  Wolffian  duct,  which  has  its 
posterior  opening  in  the  cloaca  or  hindgut,  and  thus  connects  the  two 
systems.     In  normal  development  this  duct  closes,  and  the  connection 


EMBKYOLOGY,  ANATOMY,  AXD   PHYSIOLOGY 


between  the  urinary  and  alimentary  tracts  becomes  obliterated  about 
the  twelfth  week  of  gestation.  It  will  be  noted  later  that  this  commu- 
nication sometimes  persists  and  forms  one  of  the  types  of  malforma- 
tions of  the  rectum.  With  such  intimate  relationship  in  development, 
one  is  not  surprised  to  find  these  or- 
gans closely  related  in  s3'mptomatology 
and  disease. 

During  the  development  of  the  rec- 
tum from  the  hypoblast  and  mesoblast 
there  is  going  on  an  invagination  of 
the  epiblast  or  ectoderm,  which  is 
called  the  proctodteum  (Fig.  2).  This 
invagination  increases  until  the  outer 
and  inner  layers  of  the  mesoblast  are 
pressed  together  and  absorbed,  and  the 
epiblast  of  the  proctoda?um  and  the 
hypoblast  of  the  hindgut  approach 
each  other,  and  form  a  double  ssptuni 
between  the  rectum  and  the  procto- 
dajum  or  embryonic  anus.  Testut  and 
Waldeyer  state  that  the  layers  of  the 
mesoblast  are  not  present  at  this 
point;  that  the  hindgnit  or  enteron  and 
proctodEeum  are  separated  by  to^o 
epithelial  layers,  the  one  belonging  to 
the  hypoblast,  the  other  to  the  epi- 
blast. The  existence  of  fibrous  tissue 
in  this  ssptum,  in  cases  in  which  the 
latter  has  not  been  absorbed,  would 
indicate  that  the  absence  of  the  meso- 
blast at  this  point  is  not  at  all  uni- 
form. The  absorption  of  the  SEeptum 
renders  the  conjunction  of  the  rectum 
and  anus  complete,  and  leaves  a  nar- 
row zone  that  indicates  the  transition 
from  mucous  to  muco-cutaneous  tis- 
sue, which  has  been  termed  by  Stroud 
the  ''pecten"  (Fig.  3).  This  zone 
marks  the  lower  limits  of  the  rectum  and  the  upper  margin  of  the  anus. 

The  conjunction  takes  place  generally  at  a  point  slightly  in  front 
of  the  posterior  end  of  the  gut,  and  thus  leaves  a  cul-de-sac  which,  as 
has  been  said,  is  connected  with  the  neiirenteric  canal.  This  cul-de- 
sac  and  connectino-  canal  are  laro-elv  absorbed  durins'  fcetal  life,  leaving 


Fig.  2. — DETEL0PMi:^T  of  EECxrii 
i.Schafferi. 
a,  section  of  mandibular  ai'ch ;  6,  hyp- 
ophysis,  behind  it  the  remains  of  the 
pharyngeal  seeptum ;  c,  commencing 
lung ;  d,  stomach ;  e,  liver ;  /,  yolk 
stalk ;  fif,  Wolffian  duct ;  A,  blind  por- 
tion of  hindgut. 


THE  ANUS,  RECTUM.  AND  PELVIC  COLON 


the  coccygeal  gland  or  gland  of  Luschka,  which  is  situated  just  in  front 
of  the  coccyx  and  remains  in  adult  life.  Sometimes  imperfect  absorp- 
tion leaves  a  congenital  posterior  rectocele.  It  is  from  the  remains  of 
this  posterior  cul-de-sac  and  communicating  canal  that  dermoid  cysts 
and  other  teratoid  tumors  of  the  recto-coccygeal  space  develop. 

It  will  be  seen  from  this  brief  and  incomplete  account  of  histo- 
genesis that  the  rectum  proper  is  a  development  of  the  hypoblast  and 
mesoblast  in  common  with  the  rest  of  the  colon;  that  its  muscles  and 

submucous  layer  are  from  the  inner  layer 
of  the  mesoblast,  and  that  it  logically  and 
practically  ends  with  the  serrated  margin 
of  the  pecten  or  free  borders  of  the  semi- 
lunar valves.  It  is  also  apparent  that  the 
anus,  with  all  its  surrounding  muscles, 
cells,  and  fascige,  is  a  development  of  the 
epiblast  and  outer  layer  of  the  mesoblast, 
and  histologically  includes  all  that  por- 
tion of  the  intestinal  tract  below  the  upper 
margin  of  the  pecten. 

As  will  be  seen  farther  on,  the  mem- 
branes, the  glands,  the  blood  and  nerve 
supply  all  undergo  a  more  or  less  abrupt 
change  at  this  point,  and  the  diseases 
which  we  encounter  in  the  two  portions 
are  almost  as  distinct.  It  is  necessary, 
therefore,  to  understand  exactly  the  lim- 
itations of  the  anus,  rectum,  and  sigmoid, 
and  also  to  describe  them  separately. 
They  are  discussed  consecutively  from  below  upward,  because  this  is  the 
order  in  which  they  are  met  in  examination  and  treatment. 

The  bony  outlet  of  the  pelvis  comprises  a  somewhat  diamond-shape 
space,  which  an  imaginary  line  extending  from  the  anterior  border  of 
one  tuberosity  of  the  ischium  to  the  other  divides  into  two  triangular 
spaces.  The  anterior  one  is  known  as  the  uro-genital  triangle,  and  the 
posterior  as  the  rectal  triangle  (Fig.  4).  For  convenience  of  descrip- 
tion these  triangles  are  further  divided  by  a  line  drawn  from  the  sym- 
phvsis  pubis  to  the  tip  of  the  coccyx  into  the  right  and  left  anterior 
and  posterior  quadrants. 

The  uro-genital  triangle  is  in  close  relation  with  the  anus  and 
rectum,  and  contains  important  genito-urinary  organs.  The  rectal 
triangle  contains  the  anus,  rectum,  and  surrounding  tissues.  The 
anatomy  of  the  parts  included  in  these  two  spaces  must  be  thoroughly 
understood  in  order  to  practise  rectal  surgery  successfully. 


Fig.  3. — Divi.sions  of  Axal 
Caxal  (Stroud). 
a,  skin ;  6,  Hilton's  white  line ;  c, 
pecten ;   d,  anal   papilla ;    e,   anal 
pocket ;  /,  frilled  mucosa ;  g,  liuea 
dentata ;  h,  rectal  glands. 


EMBRYOLOGY,  ANATOMY,  AND   PHYSIOLOGY 


The  Perinseum. — The  perineum  is  the  space  comprised  in  the  "uro- 
genital triangle.  It  is  bonnded  by  the  anus  behind,  the  scrotum  in 
front,  and  the  rami  of  the  ischii  upon  the  sides,  aiid  is  occupied  by  vari- 
ous important  structures.  Superficially  it  is  covered  by  the  skin,  in 
the  central  line  of 
which  there  runs  a 
rhaphe  continuous 
with  the  central 
rhaphe  of  the  scro- 
tum, and  ending  at 
the  margin  of  the 
anus.  There  is  noth- 
ing peculiar  in  this 
cutaneous  layer,  ex- 
cept that  in  the  cen- 
tral rhaphe  there  are 
few  glandular  constit- 
uents and  very  few 
hair  follicles.  Im- 
mediately beneath  the 
skin  is  found  the  su- 


FiG.  4. — Divisions  of  the  Pelvic  Ol-tlet. 
B.A.,  right  anterior  quadrant;  L.A.,  left  anterior  quadrant; 
R.P..  right  posterior  quadrant ;  £.P.,  left  posterior  quadrant; 
R.A.  and  L.A.,  uro-genital  triangle;  R.P.  and  L.P.,  rectal 
triangle. 


perficial  fascia  of  the  perinaeum,  which  is  continuous  with  the  superficial 
fascia  all  over  the  body.  It  is  not  attached  to  the  bones  or  muscles,  but 
coalesces  with  the  deep  fascia,  at  the  orifices:  beneath  this  is  found  the 
supei-ficial  perineal  fascia,  called  also  Colles's  fascia,  which  is  continu- 
ous with  the  dartos  of  the  scrotum  in  front,  attached  on  each  side  to  the 
rami  of  the  pubes  and  ischii,  and  stretched  across  the  posterior  border  of 
the  perineal  space  in  a  line  slightly  anterior  to  the  tuber  ischii.  In  front 
of  the  anus  this  fascia  dips  down  around  the  posterior  border  of  the 
transversus  perinaei  muscles,  to  be  attached  to  the  free  border  of  the 
triangular  ligament  (deep  perineal  fascia).  The  latter  structure  is  a 
dense,  fibrous  membrane  stretched  across  the  anterior  portion  of  the 
pelvic  floor.  It  is  divided  by  anatomists  into  superficial  and  deep  layers. 
Anteriorly  it  arises  from  the  superior  pubic  ligament,  is  attached  later- 
ally to  the  rami  of  the  pubes  and  ischii  a  little  deeper  than  the  cms 
penis.  Posteriorly  it  is  stretched  across  the  perineal  space,  just  above 
the  transversus  perin^ei  muscles,  and  is  continuous  with  the  posterior 
border  of  the  superficial  fascia;  while  its  attachment  anteriorly  is  above 
that  of  the  superficial  fascia,  their  posterior  borders  are  conjoined,  and 
the  two  thus  enclose  a  wedge-shaped  space  anterior  to  the  anus.  In 
this  space  are  situated  the  accelerator  urinae,  transversus  perinsei,  and 
the  erector  penis  muscles,  the  corpus  spongiosum,  the  perineal  arteries 
and  nerves,  and  the  bulbous  urethra  containing  Cowper"s  glands.     This 


6  THE  ANUS,  RECTUM,  AND   PELVIC   COLON 

wedge-shaped  space  is  divided  into  two  triangular  spaces  by  the  attach- 
ment of  the  two  walls  in  the  center  to  the  rhaphe  of  the  perineal  body 
and  the  accelerator  urinje  muscle  (Fig.  5).  These  spaces  communi- 
cate anteriorly  through  a  tract  of  cellular  tissue  at  the  junction 
of  the  scrotum  and  the  perineum.  They  are  filled  with  cellular 
tissue,  in  which  the  blood-vessels  and  nerves  of  the  generative  organs 

ramify. 

The  transversus  perinsei . muscle  crosses  the  posterior  border  of  the 
perin^eum  from  one  tuberosity  of  the  ischium  to  the  other;  the  accel- 


Fi&.  5. — Dissection  showing  Mcscclar  Arrangemext  at  Pelvic  Outlet,  Perixeal 
Triangular  Spaces,  and  Ischio-rectal  Foss^. 

erator  urinse  muscle  runs  through  the  center  of  the  space,  being  covered 
by  the  superficial  fascia,  and  these,  together  with  the  external  sphincter 
and  the  sphincter  vaginae  in  women,  unite  in  a  common  fibrous  center 
called  the  perineal  body,  just  in  front  of  the  anus.  The  deep  and  super- 
ficial fasciae  thus  enclose  important  organs  connected  with  the  uro- 
genital tract,  and  form  a  barrier  between  them  and  the  rectum. 

Ischio-rectal  Fossae. — Back  of  these  perineal  spaces,  and  separated 
from  them  by  the  wedge-shaped  border  of  the  perineal  fasciae  and  the 
transversus  perinaei  muscles,  are  situated  the  ischio-rectal  spaces  which 
practically  surround  the  lateral  and  posterior  portions  of  the  anus  and 
rectum.     They  measure  from  before  backward  5  to  8  centimeters  (2  to  3^ 


EMBRYOLOGY,   ANATOMY,   AND   PHYSIOLOGY  7 

inches),  from  side  to  side  2|-  to  3|  centimeters  (1  to  If  inch),  and  in 
depth  from  4  to  10  centimeters  (1^^  to  3|f  inches),  according  to  the 
size  of  the  subject  (Fig.  5). 

Each  fossa  forms  an  irregular,  wedge-shaped  or  cuneiform  space, 
its  base  being  directed  downward.  Each  space  is  enclosed  by  the  peri- 
neal fascias  and  the  transversus  perinsei  muscle  in  front,  the  levator 
ani  muscle  above,  the  obturator  fascias,  the  obturator  internis  muscle,  the 
ischium  and  the  sacro-ischiatic  ligaments  externall}^  the  rectum  and 
the  anus  internally,  the  gluteus  maximus  muscle,  the  sacro-sciatic 
ligaments  and  the  coccj^x  posteriorly,  and  the  skin  and  superficial  fas- 
cia below.  The  fossae  are  connected  posteriorly  by  a  zone  of  cellu- 
lar tissue  between  the  fibers  of  the  levator  ani  muscle  and  the  ano- 
coccygeal ligament.  These  spaces  are  filled  by  fat  and  cellular  tissue, 
in  which  ramify  the  blood-vessels  and  nerves  of  the  lower  end  of  the 
rectum  and  the  perineal  branch  of  the  fourth  sacral  nerve.  The  fat 
in  these  spaces  is  supported  by  a  network  of  connective-tissue  bands 
which  divides  them  into  numerous  compartments  that  communicate 
with  each  other  through  the  lymjDhatics  and  the  blood-vessels.  It  is 
owing  to  these  divisions  that  one  often  finds  in  oj)erating  upon  ab- 
scesses here  that  he  has  to  deal  with  multiple  cavities  instead  of  one  large 
excavation.  The  deepest  portion  of  the  spaces  lies  close  to  the  rectum. 
This  explains  the  fact  that  in  large  abscesses  in  this  region  the  highest 
point  is  always  nearest  the  rectal  wall.  Although  these  fossse  are 
crossed  by  numerous  blood-vessels  and  nerves,  none  of  them  is  vitally 
important  surgically,  for  the  entire  cellular  tissue  may  be  destroyed 
without  any  serious  damage  to  the  nerve  or  blood  supply  of  the  adja- 
cent organs. 

Above  the  levator  ani  muscle  are  situated  the  superior  pelvi-rectal 
and  retro-rectal  spaces,  but  these  can  be  better  understood  after  the  anus 
and  rectum  have  been  described. 

The  Anus  or  Anal  Canal. — The  anus  is  usually  described  as  a  simple 
orifice  at  the  lower  end  of  the  intestinal  tract,  but  practically  it  embraces 
all  that  portion  of  the  tract  below  the  true  mucous  membrane.  It  is 
situated  in  the  middle  of  the  pelvic  outlet  just  back  of  the  imaginary 
line  drawn  between  the  tuberosities.  In  women  it  is  slightly  farther 
forward  than  in  men,  the  distance  from  the  coccyx  measuring  in  the 
former  25  to  30  millimeters  (1  to  1^  inches),  and  in  the  latter  20  to  25 
millimeters  (f  to  1  inch).  In  a  condition  of  repose  it  appears  as  an 
antero-posterior  slit  (Fig.  6).  The  skin  around  it  is  slightly  pigmented 
and  drawn  into  folds  by  the  contraction  of  the  sphincter  muscle.  Em- 
bedded in  this  skin,  chiefly  posteriorly,  are  sudoriparous  glands  called 
circumanal  glands,  some  sebaceous  glands,  and  a  few  hair  follicles,  from 
which  issues  a  short  stumpy  growth  of  hair.     All  of  these  decrease  as 


8 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


the  central  portion  of  the  anus  is  approached,  and  disappear  altogether 
where  the  skin  changes  into  muco-cutaneous  tissue. 

Behind  the  anus  there  is  a  smooth,  dense  ridge  of  skin  extending 
to  the  posterior  surface  of  the  coccyx,  called  the  anal  rhaphe ;  in  front 

of  it  is  the  perineal  rhaphe 
proper,  which  has  been 
already  described.  As  the 
center  of  the  anus  is  ap- 
proached the  skin  loses 
its  corneous  character, 
gradually  changing  into 
muco-cutaneous  tissue, 
which  is  finally  trans- 
formed into  mucous  mem- 
brane at  the  upper  end  of 
the  anal  canal. 

Dimensions. — The  anal 
canal  is  limited  by  the 
true  skin  below  and  the 
free  borders  of  the  semi- 
lunar valves  or  the  ano- 
rectal line  of  Testut 
(Traite  d'anatomie  hu- 
maine,  vol.  iv,  p.  "23-i). 
It  measures  from  16  to 
2-t  millimeters  (|  to  1 
Fio.  6.— N  KMAi  ams  IX  Eepose.  inch)    in   length.     Its   cir- 

cumference varies  from 
3  centimeters  {l-j\  inch)  in  normal  condition  to  15  centimeters  (oy^-g- 
inches)  in  disease,  following  injury  or  vicious  practices.  The  average 
anus  will  admit  a  cylinder  of  65  millimeters  in  circumference  without 
rupturing  the  mucous  membrane. 

The  walls  of  the  anal  canal  are  composed  of  muco-cutaneous,  fibro- 
cellular,  and  muscular  layers.  The  muco-cutaneous  layer  is  smooth, 
shiny,  and  glossy.  It  contains  few  glands  and  blood-vessels,  but  it  is 
richly  endowed  with  terminal  nerve-ends.  It  is  covered  in  its  lower 
portion  by  stratified,  squamous  epithelium,  which  undergoes  a  gradual 
transformation  until  it  ends  in  the  typical  columnar  epithelium  of  the 
mucous  membrane  at  the  upper  margin  of  the  linea  dentata  or  ano- 
rectal line.  This  irregular  border  limits  the  upper  end  of  the  anus, 
and  forms  the  central  floor  of  the  rectal  ampulla.  The  dentations  are 
slightly  elevated  above  the  surface  of  the  adjoining  mucosa,  and  form 
an  irregular  ridge  between  the  rectum  proper  and  the  anal  canal.     They 


EMBRYOLOGY,  AXATOMY,   AND   PHYSIOLOGY 


Yarv  in  number  from  five  to  eight,  and  assume  tlie  form  of  papillae  at 
their  summits.  Andre"«-s  (Diseases  of  the  Eectum,  1895,  p.  303)  con- 
siders tliese  papilla?  the  normal  tactile  organs  of  the  rectum  endowed 
with  a  special  rectal  sense.  Stroud,  however,  states  that  they  are  ab- 
normal structures  growing  from  the  tips  or  faces  of  the  indentations. 
He  found  in  them  epidermal,  dermal,  and  amyelinic  nerve-fibers.  They 
are  absent,  or  at  least  not  noticeable  in  the  large  majority  of  cases;  but 
when  they  are  well  developed  they  produce  many  reflex  disturbances 
which  are  accounted  for  by.  their  abundant  nerve  supply  (Fig.  7). 

In  the  upper  portion  of  the  muco-cutaneous  tissue  one  finds  a  few 
irregular,  tubular  glands  analogous  to  those  seen  in  the  rectum.  Stroud 
calls  them  accidental  glands,  but  Hermann  considers  them  as  simple 
mucous  crypts.  About  4  to  5  millimeters  (y^g-  of  an  inch)  below  the 
ano-rectal  line  there 
is  a  poorly  defined  line 
or  depression  which 
marks  the  lower  end 
of  the  internal  sphinc- 
ter, and  is  known  as 
Hilton's  white  line. 
In  many  cases  this  is 
almost  imperceptible 
to  the  eye,  but  it  can 
always  be  made  out  by 
touch,  as  it  marks  the 
juncture  between  the 
internal  and  external 
sphincter  muscles. 

The     Fihro-ceUidar 
Layer. — Beneath     the 

muco-cutaneous  tissue,  and  separating  it  from  the  muscular  layer,  is  a 
thin  fibro-cellular  layer  of  the  anal  canal.  Above  Hilton's  white  line 
this  layer  is  chiefly  cellular,  below  this  point  it  develops  into  a  thin 
layer  of  connective  tissue  continuous  with  the  superficial  fascia  cover- 
ing the  isehio-rectal  foss^.  It  is  closely  attached  to  the  muco-cutaneous 
and  muscular  layers,  thus  uniting  the  two  and  preventing  any  great 
movement  of  one  upon  the  other. 

The  Muscular  Layer. — The  anal  canal  is  surrounded  by  the  external 
sphincter,  some  fibers  of  the  levator  ani,  the  longitudinal  muscular  fibers 
of  the  rectum,  and  a  few  of  the  circular  fibers  comprising  the  lower  por- 
tion of  the  internal  sphincter.  The  external  sphincter  forms  the  chief 
muscular  wall  of  the  anal  canal.  A  few  interlacing  fibers  of  the  levator 
ani  and  the  longitudinal  muscles  of  the  rectal  wall  pass  do^vn  between 


Fig.  7. — The  Anal  Caxal. 
A,  columns  of  Morgagni:  i?,  semilunar  valves  or  crypts  of 
Morgagni ;  C,  dentate  border  marking  upper  limits  of  anus 
and  surmounted  by  papillas ;  J),  Hilton's  -n-hite  line. 


10 


THE  ANUS,  RECTUM,  AXD   PELVIC  COLON 


its  fibers  and  around  its  lower  margin  to  be  attached  to  the  deeper  lay- 
ers of  the  skin,  and  thus  comprise  a  portion  of  the  muscular  wall.  The 
arrangement  of  these  fibers  will  be  seen  in  the  illustration  (Fig.  8). 

The  External  Sphincter  Muscle. — The  external  sphincter  is  com- 
posed of  voluntary  or  striated  muscular  fibers,  and  from  a  surgical  point 
of  view  is  the  most  important  muscle  of  the  rectum.    It  arises  from  the 


4i.    "^     \ 


Fig.  8. — Loxgitudixal  Sectiox  of  Axal  Walls,  showing  Aeraxgement  of 
MrsccLAR  Fibers. 
A,  circular  muscular  fibers  of  intestine  ending  in  internal  sphincter  below ;  B,  longritudinal 
muscular  fibers  of  gut  penetrating  external  sphincter;   C.  fibers  of  levator  ani,  some  cut 
transversely  in  upper  portion,  and  others  longitudinally  where  they  are  united  to  gut  wall 
and  proceed  downward ;  D,  external  sphincter. 


posterior  surface  of  the  coccyx  and  the  fibrous  layer  of  the  skin  over 
this  region,  passes  forward  to  the  posterior  commissure  of  the  anus, 
where  its  parallel  fibers  divide  to  surround  this  aperture,  and  reuniting 
at  the  anterior  commissure,  pass  forward  to  be  inserted  into  the  perineal 
bod}'.  It  is  composed  of  a  superficial  and  deep  layer.  The  fibers  of 
the  superficial  layer  are  circular  and  entirely  surround  the  anus  (Fig. 
5).  The  fibers  of  the  deep  layer  are  parallel,  and  simply  separate  and 
apply  themselves  to  the  anal  portion  of  the  rectum  to  the  height  of  1  to 


EMBRYOLOGY,  ANATOMY,   AND   PHYSIOLOGY 


11 


3  centimeters  (f  to  |  of  an  inch).  In  women  it  is  continuous  in  front 
with  the  fibers  of  the  sphincter  vaginas  (Fig.  9).  Inside  of  the  external 
sphincter  the  fibers  of  the  levator  ani,  the  longitudinal  muscles,  and  the 
internal  sphincter,  which  form  a  part  of  the  walls  of  the  anal  canal, 
are  found. 

Erect,  clit. 

Muse.  bulb.  cav. 


Levator  Ani  Muscle. — The  levator  ani  is  a  broad  sheet  of  muscular 
fibers  which  forms  the  supporting  floor  of  the  pelvic  cavity  (Fig.  10).  It 
arises  in  front  upon  each  side  of  the  symphysis  pubis,  laterally  from  the 
pelvic  fascia  along  the  line  of  its  attachment  with  the  obturator  fascia, 
and  posteriorly  from  the  spine  of  the  ischium  on  each  side  of  the  pelvis. 


12 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


Its  anterior  fibers  pass  downward  and  backward  around  the  prostate 
gland  to  unite  with  the  fibers  of  the  opposite  side  beneath  the  neck  of  the 
bladder;  the  middle  fibers  pass  downward  and  inward  around  the  rectum, 
some  being  attached  to  the  sides  of  this  organ,  and  interlacing  at  their 
lower  ends  with  the  fibers  of  the  external  sphincter,  while  others  unite 
posteriorly  and  pass  backward  to  be  inserted  on  the  anterior  surface  of 
the  coccyx.  The  posterior  fibers  pass  downward  and  backward,  and  are 
inserted  upon  the  sides  of  the  coccyx  and  lower  part  of  the  sacrum. 


Fig.  10. — Levator  Ani  Muscle. 
Drawn  from  dissection  by  tlie  author. 


Cripps  (Diseases  of  the  Kectum,  p.  9)  states  that  this  muscle  crosses 
the  rectum  at  right  angles,  and  thus  encloses  this  organ  in  the  narrow 
angle  of  a  V-shaped  muscular  formation,  in  consequence  of  which  its 
only  action  is  to  constrict  the  rectum  (Fig.  11).  Upon  this  anatomi- 
cal construction  he  has  based  his  ingenious  theory  of  spasmodic  stric- 
ture. Numero.us  dissections  have  failed  to  show  any  other  arrange- 
ments than  illustrated  in  Fig.  10.  Viewed  from  below,  the  muscle  ap- 
pears as  an  inverted  dome,  and  the  contraction  of  its  fibers  not  only 
lifts  but  also  constricts  the  rectum  and  anus.  Its  fibers  are  not  uniformly 
spread  out,  but  are  collected  in  small  bundles,  the  spaces  between  these 
being  occupied  by  fibrous  tissue. 


EMBRYOLOGY,   ANATOMY,   AND   PHYSIOLOGY 


13 


Iscliio-coccygeus  Muscle. — Anatomists  describe  the  posterior  fibers 
of  the  levator  ani  as  a  distinct  muscle  under  the  above  name.  The  por- 
tion so  described  arises  from  the  rami  and  spine  of  the  ischium  and 
from  the  border  of  the  sacro-ischiatic  ligament,  and  passes  downward, 
inward,  and  backward,  to  be  inserted  b}'  aponeurotic  fibers  upon  the 
sides  of  the  coccyx  and  last  sacral  vertebra.  This  portion  of  the  muscle 
is  somewhat  more  fibrous  than  the  anterior  portion;  its  function  seems 
to  be  that  of  pulling  the  coccyx  forward.  It  forms  the  floor  of  the 
pelvis  posterior  to  the 
rectum. 

The  author  sees  no 
reason  for  describing  it 
as  a  separate  muscle, 
and  therefore  when  ref- 
erence is  made  to  the 
levator  ani  in  this  book 
the  entire  muscular 
plane  or  floor  of  the 
pelvis  will  be  meant. 

Redo-coccygeus  Mus- 
cle.— Under  this  name, 
and  also  under  the 
names  tensor  fasciae  pel- 
vis (Kohlrausch)  and  re- 
tractores  recti  (Treitz), 
two  flat  bands  of  un- 
striped  •  muscular  fibers 
have  been  described, 
which  are  said  to  arise 
from  the  coccygeal  liga- 
ment near  the  tip  of  the 
coccyx,  and  pass  forward 
and  downward,  finally 
blending  with  the  longitudinal  muscular  fibers  of  the  rectum  and  the 
pelvic  fascia  around  the  anus. 

Relations  of  the  Anal  Canal. — According  to  the  foregoing  descrip- 
tions, the  relations  of  the  anal  canal  are  as  follows :  Anteriorly  it  is  in 
relation  with  the  perineal  body,  the  deep  layer  of  the  superficial  peri- 
neal fascia,  the  posterior  border  of  the  triangular  ligament,  and  the 
anterior  fibers  of  the  levator  ani  muscle;  laterally  with  the  perianal 
fasciae,  which  separate  it  from  the  ischio-rectal  fossae,  and  with  the  ex- 
ternal sphincter  muscle;  posteriorly  it  is  in  relation  with  the  external 
sphincter,  the  levator  ani,  and  the  ano-coceygeal  ligament. 


Fig.  11. — Levator  Ani  Muscle  (Cripps). 

A,  anus ;  B,  bladder ;   C,  coccyx ;  B,  rectum  ;  S,  symphysis 

pubis ;  LA,  levator  ani  muscle. 


14  THE  ANUS,   RECTUM.   AND   PELVIC  COLON 

The  blood-vessels,  nerves,  and  lymphatics  of  the  anus  are  so  inti- 
mately connected  with  those  of  the  rectum  proper  that  it  is  deemed 
advisable  to  describe  them  all  too^ether. 


THE    RECTUM 

The  rectum,  as  defined,  comprises  that  portion  of  the  intestinal 
canal  between  the  semilunar  valves  of  Morgagni  and  the  attachment  of 
the  mesentery  opposite  the  third  sacral  vertebra.  Treves  first  advocated 
this  division.  It  gives  to  the  organ  definite  limits ;  it  separates  the 
mobile  from  the  immobile  portion  of  the  gut ;  it  marks  the  line  where 
the  course  of  the  blood  snpply  changes;  it  indicates  the  point  where 
the  three  longitudinal  muscular  bands  of  the  colon  spread  out  and  be- 
come more  or  less  equably  distributed  around  the  gut;  and,  finally,  it 
marks  a  point  at  which  there  is  always  a  decided  narrowing  in  caliber, 
indicating  the  juncture  of  the  rectum  with  the  pelvic  colon. 

According  to  this  division,  that  portion  of  the  rectum  which  is  ordi- 
narily called  the  superior  or  first  portion  is  included  in  the  sigmoid  flex- 
ure under  the  term  pelvic  colon,  and  Justly  so,  as  it  corresponds  in  every 
anatomical  detail  with  the  other  loops  of  this  organ. 

Course  and  Direction. — The  name  rectum  would  imply  that  the 
organ  is  straight,  but  such  is  not  the  case.  Beginning  in  the  hollow  of 
the  sacrum,  it  follows  the  sacro-coccygeal  curve  do\\'nward,  being  first 
directed  backward,  then  forward,  and  finally  backward  again  at  the  anal 
canal.  It  thus  forms  a  double  antero-posterior  curve,  the  concavity  of 
which  is  directed  fom'ard  in  the  superior  portion  and  backward  in  the 
lower  or  prostatic  portion.  It  begins  ordinarily  opposite  the  center 
of  the  sacrum,  passes  outward  to  the  right  beyond  the  central  line,  and 
then  again  to  the  left,  thus  making  two  lateral  curves  as  it  descends. 
These  curvatures  are  not  marked,  and  the}'  are  of  no  great  practical 
importance.  The  antero-posterior  curvatures  are  well  marked,  how- 
ever, and  indicate  the  direction  in  which  the  finger  or  instruments 
should  be  directed  in  introducing  them  into  the  organ.  They  are  more 
marked  in  some  individuals  than  in  others,  and  may  be  greatly  in- 
creased by  tumors,  displaced  uteri,  or  pelvic  adhesions. 

Above  the  third  sacral  vertebra  the  sigmoid  begins :  the  canal  may 
turn  to  either  the  right  or  left;  the  angle  may  be  sharp  or  obtuse, 
and  there  is  no  way  of  accurately  determining  this  except  by  ocular 
inspection. 

Divisions. — The  rectum  may  be  divided  into  two  portions — the  in- 
ferior or  prostatic  portion,  and  the  superior  or  sacro-coccygeal  portion. 
The  inferior  portion  is  very  short,  and  extends  from  the  ano-rectal  line 


EMBRYOLOGY,  ANATOMY,   AND  PHYSIOLOGY  15 

or  upper  border  of  the  crypts  of  Morgagni  to  the  summit  of  the  prostate. 
The  superior  portion  extends  from  the  summit  of  the  prostate  to  the 
middle  of  the  third  sacral  vertebra. 

Some  writers  subdivide  the  upper  portion  of  the  rectum  into  peri- 
toneal and  infraperitoneal  portions.  This  division,  however,  is  im- 
practical, inasmuch  as  it  is  impossible  to  determine  the  lower  limits  of 
the  peritoneal  covering.  Numerous  divisions  and  subdivisions  are  con- 
fusing, and  the  author  prefers  to  study  the  organ  as  a  whole. 

Dimensions. — The  length  of  the  rectum  is  10  to  15  centimeters  (3-^-f- 
to  5^  inches)  in  men,  and  9  to  13  centimeters  (3f  to  5^  inches)  in 
women.  This  varies  according  to  the  size  of  the  individual,  and  is  some- 
what greater  in  old  people  than  in  young.  These  measurements  are  less. 
than  those  ordinarily  given,  on  account  of  the  fact  that  they  do  not 
include  the  first  or  superior  portion  of  the  rectum  in  the  old  divisions. 

The  diameter  is  very  difficult  to  obtain  in  the  living  subject.  It 
measures  when  empty  10  to  20  millimeters  from  before  backward,  and 
30  to  40  millimeters  from  side  to  side.  When  distended,  or  removed 
from  the  body  and  spread  open,  its  measurements  vary  greatly,  and 
sometimes  assume  enormous  proportions.  Sappey  has  reported  a  case 
in  which  the  gut  measured  34  centimeters  (13|  inches)  in  circumfer- 
ence at  its  widest  point.  From  the  chapter  on  Foreign  Bodies  in  the 
Rectum  one  will  gain  some  idea  of  the  extent  to  which  the  organ  may 
be  dilated. 

The  circumference  varies  in  the  different  portions  of  the  organ,, 
being  on  an  average  6  to  10  centimeters  in  the  prostatic  portion,  13  to- 
20  centimeters  in  the  widest  portion  of  the  ampulla,  and  10  to  14  centi- 
meters in  its  upper  or  narrow  portion.  Numerous  instances  have  been 
recorded  in  which  these  figures  were  greatly  exceeded.  Quenu  and 
Hartmann,  after  having  excised  and  split  open  a  large  number  of  recti,, 
give  the  following  average  circumference :  Anus,  5  to  9  centimeters ; 
rectal  ampulla,  13  to  16  centimeters  below  and  8  to  10  centimeters 
above;  the  tubular  portion,  or  the  last  loop  of  the  sigmoid  according 
to  our  division,  10  to  12  centimeters. 

Conformation. — When  the  rectum  is  empty,  the  anterior  walls  are 
pressed  backward  by  the  pelvic  contents,  and  thus  come  in  close  ap- 
position Avith  the  posterior  walls.  Thus  there  is  formed  a  lateral  slit 
or  flattened  canal,  much  wider  from  side  to  side  than  from  before 
backward.  When  distended  with  gas,  liquids,  or  solid  substances,  the 
organ  assumes  an  irregular  cylindrical  shape.  It  is  often  wider  from 
side  to  side  than  from  before  backward  on  account  of  pressure  by  the 
pelvic  organs,  or  through  adhesive  bands  which  prevent  its  being,  dis- 
tended as  much  in  the  antero-posterior  direction  as  in  the  lateral.  The 
irregular  shape  of  the  organ  will  be  appreciated  by  referring  to  several 


16 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


i-'iG.  li!. — Cast  uf  liEoxuii  s  QiK'nu  and 
Hartmaim). 


Fig.  ]3.- 


-Cast  of  Eectum  (Quenu  and 
Ilartinann). 


illustrations  (Figs.  12  to  17)  of  casts  made  by  filling  the  organ  with  plas- 
ter of  Paris,  paraffin,  and  other  such  substances. 

In  certain  cases  of  atony,  or  where  the  rectum  has  been  greatly  dis- 
tended, it  assumes  a  very  irregular  shape,  the  sacculi  resolving  them- 


Fii..    i  k  -I  AST  OF  Rectcm  a-nd  Axal  Canal, 

Sl)0\viiig  irregular  curves  in  fornaer. 

(Quenu  and  Hartmaun.) 


15. — Cast  of  Rectum  and  Lower 
Loop  of  Sigmoid  (Martin). 


EMBRYOLOGY,  ANATOMY,   AND   PHYSIOLOGY 


17 


selves  into  true  diverticuli.  In  other  cases,  especially  where  there  has 
been  a  protracted  rectitis,  the  organ  assumes  a  cylindrical  or  tubular 
shape,  with  slight  variation  in  caliber  from  the  apex  of  the  prostate 
upward.     This  condition  is  the  normal  one  in  children,  and  is  said  by 


Fig.  16. — Cast  of  Eectuii. 
Showing  sudden  contraction  in  caliber  at  junc- 
ture with  sigmoid.     (Quenn  and  Hartmann.) 


Fig.  17. — Cast  of  Kectum  and  Anal 
Canal  (Queuu  aud  Hartmann). 


Gaily  to  occur  once  in  every  six  adults.  This  proportion,  however, 
appears  to  the  author  to  be  largely  overestimated. 

The  external  surface  is  irregularly  convoluted,  but  less  so  than  the 
sigmoid  flexure.  The  grooves  which  mark  its  contour  correspond  with 
the  site  of  the  mucous  folds  or  Houston's  valves  internally. 

Anatomical  Structure. — The  walls  of  the  rectum  are  composed  of 
four  layers  or  coats.  From  within  outward  they  comprise  the  mucous, 
the  submucous,  the  muscular,  and  the  serous  layers. 

The  Mucous  Membrane. — The  mucous  membrane  of  the  rectum 
differs  from  that  of  the  upper  colon  in  that  it  is  thicker,  darker  in  color, 
more  vascular,  and  more  mobile,  being  attached  to  the  muscular  wall 
through  a  loose,  lax,  submucous  tissue,  which  allows  it  to  slide  in  all 
directions.  It  is  characterized  by  a  great  development  of  tubular  and 
muciparous  glands,  together  with  many  closed  follicles  and  an  ex- 
tensive vascular  apparatus.  Throughout  its  extent  it  is  thrown  into 
loose  horizontal  folds,  some  of  which  correspond  with  the  valves  of 
Houston.  In  its  lower  portion  it  is  gathered  into  longitudinal  folds, 
constituting  the  columns  of  Morgagni,  between  the  bases  of  which  are 
2 


18  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

found  the  semilunar  valves  or  crypts  of  Morgagni,  the  free  borders  of 
which  mark  the  limitation  of  the  rectum  above  and  the  anus  below. 

Structure  of  the  Mucous  Memhrane. — The  membrane  is  composed  of 
three  layers :  the  epithelial,  glandular,  and  muscular.  The  epithelial 
layer  consists  of  a  layer  of  columnar  cells  throughout  the  rectum  proper. 
This  changes,  however,  into  stratified  polyhedral  and  prismatic  layers  in 
the  transitional  zone  at  the  lower  end  of  the  organ.  Below  the  epitheli- 
um there  are  numerous  closed  follicles;  between  these  follicles  are  the 
glands  of  Lieberkiihn,  which  practically  compose  the  substance  of  the 
mucous  membrane. 

The  glands  in  the  rectum,  chiefly  Lieberkiihn's  follicles,  differ  some- 
what from  those  in  the  upper  portion  of  the  colon  in  containing  more 
goblet  or  mucus-secreting  cells.  The  glands  are  tubular  and  are  very 
close  together,  the  intervening  tissue  measuring  about  one-sixth  the 
diameter  of  the  tubes. 

The  cells  lining  the  tubules  are  arranged  at  right  angles  to  the 
cavity,  and  are  continuous  with  those  covering  the  mucous  membrane 
between  the  tubules.  The  arrangement  of  these  tubules  is  similar  to 
that  of  a  honeycomb,  the  division  between  any  two  forming  a  common 
wall  for  each  of  them. 

The  intertubular  tissues  are  composed  of  a  fine  trabecular  network, 
the  long  meshes  of  which  run  parallel  to  the  tubules,  forming,  accord- 
ing to  Cripps  and  Testut,  lymph-paths.  Practically,  the  Lieberkiihn 
follicles  are  nothing  more  than  inverted  villi.  They  are  said  to  be 
inverted  on  account  of  the  solid  condition  of  the  material  with  which 
they  come  in  contact,  but  their  function  remains  the  same  as  that  of  the 
villi — viz.,  the  absorption  of  the  fluid  contents  of  the  bowel.  The  ab- 
sorption takes  place  through  the  epithelium  or  through  the  intervening 
spaces,  more  probably  through  the  former. 

At  the  lower  end  of  the  rectum  are  found  numerous  compound 
racemose  glands,  called  by  Schaffer  anal  glands.  Here  and  there  be- 
tween the  Lieberkiihn  glands  are  found  small  nodules  of  lymphoid 
tissue,  which  are  said  to  possess  a  very  feeble  vitality.  These  have  no 
mouths  or  openings  connecting  them  with  the  cavity  of  the  rectum,  and 
no  connection  with  the  lymphatics,  so  far  as  has  been  discovered. 

The  muscular  layer  of  the  mucous  membrane,  called  the  muscu- 
laris  mucosa,  is  somewhat  more  developed  in  the  rectum  than  in  the 
other  portions  of  the  colon.  Kohlrausch  (Anat.  u.  Physiol,  der  Beck- 
enorgane,  Leipzig,  1854)  described  these  fibers  under  the  name  of 
sustentator  tunicas  mucosfe.  Treitz  states  that  the  fibers  are  specially 
developed  in  the  columns  of  Morgagni,  but  other  anatomists  have  failed 
to  establish  this  fact.  The  exact  functions  of  these  minute  fibers  are 
not  known. 


EMBRYOLOGY.  AXATOMY.  AND   PHYSIOLOGY 


19 


Submucous  Layer. — The  submucous  tissue  of  the  rectum  consists  in 
a  loose^,  alveolar  network  of  elastic  tissue  and  connective-tissue  cells. 
It  is  thicker  and  more  elastic  than  at  any  other  portion  of  the  intestinal 
canal,  and  thus  allows  a  greater  mobility  of  the  mucous  membrane 
above  it.  In  this  tissue  ramify  the  blood-vessels,  nerves,  and  lymphatics. 
In  certain  diseases  it  becomes  greatly  hypertrophied,  and  may  become 
entirely  transformed  into  fibrous  tissue. 

Muscular  Wall. — The  muscular  coat  of  the  rectum  is  composed  of 
circular  and  longitudinal  fibers.     The  circular  fibers  compose  the  inter- 


FiG.  IS. — Ap.EA^'GE3Ii:^■T  of  Ciecclar 
Muscular  Fibers  of  Eectum. 


Fig.  Ifi. — DiAGRAiiitATic  Illusteatiox  of 
Chief  Aggregations  of  Circuxar  Mus- 
cular Fibers  en"  Eectal  "Wall. 


nal  layer.  This  layer  is  irregular  in  its  distribution,  the  fibers  being 
aggregated  at  different  levels  upon  one  part  of  the  circumference  and 
spread  out  at  the  other  (Figs.  18,  19).  The  chief  aggregation  of  fibers 
is  at  the  lower  end,  where  they  go  to  make  up  the  internal  sphincter. 
The  muscular  fibers  throughout  the  rectum  are  separated  by  connective- 
tissue  fibers  arranged  parallel  to  them.  This  arrangement  apparently 
accounts  for  the  rapid  development  of  the  connective-tissue  strictures 
in  inflamed  conditions. 

Internal  Sphincter. — This  muscle,  composed  of  an  aggregation  of 
circular  fibers,  begins  about  1  centimeters  above  the  anal  margin,  and 
gradually  increases  in  thickness  until  it  reaches  the  ano-rectal  line,  after 


20  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

which  it  thins  out  again  and  disappears  about  the  middle  of  the  anal 
canal  (Fig.  8).  Its  width  from  above  downward  averages  1  to  3  cen- 
timeters (f  to  1^  inch).  Its  thickness  is  so  variable  that  no  accurate 
measurement  can  be  given.  Its  lower  fibers  are  below  and  within  the 
grasp  of  the  external  sphincter,  from  which  it  is  separated  by  a  narrow 
zone  of  connective  tissue  (Fig.  8). 

A  depressed  zone,  not  always  perceptible  to  the  eye  but  appreciable 
by  digital  touch,  marks  the  line  of  division  between  these  two  muscles. 
The  internal  sphincter  is  purely  an  involuntary  muscle,  but  it  is  looked 
upon  by  many  surgeons  as  the  most  important  factor  in  faecal  continence, 
and  in  the  production  of  constipation. 

The  Third  Sphincter. — Aggregations  of  circular  fibers  at  different 
levels  of  the  rectum  have  been  the  cause  of  much  controversy.  Velpeau 
(Traite  d'anat.  chir.,  1837,  p.  39)  says:  "  Xelaton  described  a  muscle 
which  he  called  the  superior  sphincter,  and  which  is  situated  about  4 
inches  above  the  anus,  about  the  spot  where  strictures  of  the  rectum 
are  generally  observed.  It  is  formed  of  fibers  which  are  both  aggregated 
and  fan-shaped.  Its  depth  in  front  is  about  six  to  seven  lines,  while 
posterior  and  on  the  sides  it  is  spread  out  to  about  1  inch."  Velpeau, 
while  denying  some  of  the  functions  attributed  to  the  muscle,  confirmed 
Xelaton's  description,  and  Gosselin  (Arch.  gen.  de  med.,  1854,  p.  668)  de- 
scribed this  aggregation  as  dividing  the  upper  and  middle  portions  of 
the  rectum. 

Hyrtl  (Topog.  Anat.,  p.  162)  described  this  aggregation.  He 
frankly  confessed  that  his  dissections  failed  to  confirm  its  uniform  pres- 
ence, but,  reasoning  from  physiological  phenomena,  claimed  that  there 
was  a  true  circular  sphincter  entirely  surrounding  the  rectum  at  this 
point.  His  claims  have  not  been  verified  by  Sappey  (Traite  d'anatomie 
humaine,  p.  272).  Chadwick  (Transactions  of  the  American  Gynaeco- 
logical Society,  vol.  ii,  1877),  Lamier  and  Testut  {op.  cit.,  vol.  iv,  p.  211) 
have  all  practically  verified  Xelaton's  statement.  There  are  also  similar 
aggregations  above  and  below  this  point  (Fig.  20).  It  is  generally  con- 
ceded that  these  aggregations  of  circular  fibers  occur  at  the  base  of  Hous- 
ton's valves,  and  that  the  muscular  fibers  extend  into  the  layers  of  these 
valves.  O'Beirne  (Xew  Views  of  the  Process  of  Defecation,  Dublin. 
1833)  described  the  aggregation  found  at  the  juncture  of  the  sigmoid 
and  rectum  as  the  third  sphincter,  and  attributed  to  it  a  most  important 
role  in  the  act  of  defecation.  Dissection  has  demonstrated  the  existence 
of  an  aggregation  of  circular  fibers  on  the  concave  surface  of  the  gut  at 
this  point,  the  fibers  of  which  spread  out  upon  the  sides  and  convexity 
(Fig.  19).  It  is  claimed  that  the  action  of  suth  a  muscle  will  constrict 
the  gut  at  the  point  where  the  fibers  are  concentrated,  and  this  muscular 
constriction  can  be  easily  demonstrated  through  the  modern  proctoscope. 


EMBRYOLOGY,   ANATOMY,  AND   PHYSIOLOGY 


21 


From  the  casts  made  of  the  rectum  and  microscopic  examination  of  the 
intestinal  walls,  it  has  been  shown  that  there  exist  at  every  flexure  of 
the  rectum  and  colon  an  aggregation  of  circular  fibers  proportionate  to 
the  acuteness  of  the  flexure ;  that  in  the  rectum  these  aggregations  are 
situated  opposite  the  insertion  of  the  valves  of  Houston,  and,  finally, 
the  chief  aggregations  occur  about  3  inches  above  the  margin  of  the 
anus  and  at  the  Junction  of  the  rec- 
tum and  sigmoid.  Assuming  that 
a  perfect  ring  of  aggregated  circu- 
lar fibers  is  necessary  to  the  forma- 
tion of  a  sphincter,  it  must  be  ad- 
mitted that  there  is  no  anatomical 
conformation  above  the  internal 
sphincter  to  which  this  term  can 
be  applied.  On  the  other  hand,  if 
we  consider  the  semicircular  aggre- 
gations as  sphincters,  one  must  ad- 
mit not  only  a  third  but  a  fourth, 
fifth,  and  even  more  sphincters. 
Such  a  nomenclature  would  be  con- 
,  fusing,  and  therefore  these  aggre- 
gations should  be  called  the  semi- 
circular muscles  of  the  rectum, 
and  the  term  third  sphincter 
should  be  discarded. 

Longitudinal  Muscular  Layer. — 
Outside  of  the  circular  fibers  is  the 
longitudinal  muscular  layer  of  the 
rectum.     This  layer  is  a  continua- 
tion of  the  three  longitudinal  mus- 
cular bands  of  the  colon  which  coalesce  at  the  juncture  of  the  rectum 
and  sigmoid,  and  spread  out,  forming  a  distinct  coat  around  the  rectum, 
somewhat  thicker  in  front  and  behind  than  upon  the  sides.     This  layer 
is  divided  by  anatomists  into  external,  middle,  and  internal  portions. 

The  external  fibers  pass  downward  and  are  inserted  into  the  superior 
pelvic  fascia  covering  the  upper  surface  of  the  levator  ani  muscle.  The 
middle  fibers  mingle  with  those  of  the  levator  ani,  and  are  attached  with 
them  to  the  rectal  wall.  The  internal  fibers  pass  downward,  together 
with  some  fibers  from  the  levator  ani  between  the  two  sphincters,  and 
are  inserted  in  the  superficial  fascia  surrounding  the  anus.  Goodsall 
and  Miles  state  that  these  fibers  can  be  seen  to  pass  between  the  deep 
and  superficial  layers  of  the  external  sphincter  muscle.  The  arrange- 
ment of  these  fibers  in  the  upper  portion  of  the  rectum  is  very  irregular. 


Fig.  20. — Dissection  by  Martin. 

Showing  fan-shaped  arrangement  of  circular 

muscular  fibers. 


22 


THE   ANUS,   RECTUM,  AND   PELVIC   COLON 


i..  ^ 


Ip 


as  will  be  seen  from  the  illustration   (Fig.   21)   taken  from  Lamier. 
Sometimes  they  dip  into  the  flexures  of  the  gut,  and  at  others  they  pass 

over  the  same. 

Outside  of  the  longitudinal  muscular  layer 
in  the  lower  portion  of  the  rectum  the  walls 
are  reenforced  by  the  fibers  of  the  levator  ani 
muscle. 

Serous  Coat. — Beginning  at  the  lower 
point  of  the  pelvic  peritoneal  cul-de-sac,  the 
peritonaeum  covers  the  anterior  surface  of  the 
rectum,  and,  passing  upward  and  backward 
in  an  oblique  line,  finally  invests  the  entire 
circumference  of  the  organ  at  about  the  level 
of  the  third  sacral  vertebra.  As  this  coat 
passes  upward  it  is  reflected  externally  upon 
the  sides  of  the  pelvis,  thus  forming  the  lat- 
eral supports  of  the  rectum  (Fig.  22).  At 
the  level  of  the  third  sacral  vertebra  the  two 
folds  of  peritoneum  unite  posteriorly  to 
form  the  pelvic  mesocolon  or  mesorectum. 
Anteriorly  the  serous  coat  is  reflected  upon 
the  bladder  in  males  and  the  uterus  in  fe- 
males, thus  forming  the  recto-vesical  or  Doug- 
las's cul-de-sac.  These  culs-de-sac  contain  the 
sigmoid  flexure,  loops  of  small  intestine,  and 
sometimes  the  caecum,  vermiform  appendix, 
and  the  ovaries.  The  depth  to  which  they 
extend  upon  the  anterior  surface  of  the  rec- 
tum varies  in  individuals  and  under  different 
circumstances.  With  the  bladder  and  rectum  empty,  they  extend  to 
within  6  centimeters  of  the  margin  of  the  anus;  but  when  these  organs 
are  distended  this  distance  may  be  increased  to  9  or  even  12  centimeters 
(4f  inches).  They  are  about  1  to  2  centimeters  nearer  the  anal  mar- 
gin in  women  than  in  men.  In  cases  of  procidentia  with  rectal  hernia, 
or  where  the  perinasum  has  been  injured  during  childbirth,  the  culs-de- 
sac  sometimes  approach  very  near  the  perineal  surface.  In  one  case 
the  cul-de-sac  was  separated  from  the  perinaeum  by  only  the  thickness 
of  the  external  sphincter  muscle.  These  variations  are  rendered  im- 
portant by  the  fact  that  the  culs-de-sac,  when  extending  abnormally  low, 
may  be  easily  penetrated  in  operations  upon  the  anterior  wall  of  the 
rectum. 

Columns  of  Morgagni,  Pillars  of  Glisson,  Columns  of  the  Rectum. 
— The  mucous  membrane  at  the  lower  end  of  the  rectum  is  gathered 


Fig.  21. 

Arrangement  of  Longitudi- 
nal Muscular  Layer  of  the 
Eectum  (Lamier). 

a,  b,  c,  d,  grooves  of  rectal  cylin- 
der; t,  t',  longitudinal  fibers 
forming  woven  bundle  ;  s,  lon- 
gitudinal band  arising  in  part 
from  circular  fibers;  Ip,  fan- 
shaped  bands  arising  from 
both  muscular  layers;  y,  fas- 
ciculus splitting  off  from  lon- 
gitudinal bundle,  t,  t' . 


EMBRYOLOGY,   AXATOMY,   AXD   PHYSIOLOGY 


23 


together  into  longitudinal  folds  designated  by  the  above  names.  They 
are  rendered  more  prominent  by  the  contraction  of  the  sphincter,  and 
obliterated  by  dilatation  of  the  canal.  The  base  of  each  column  joins 
with  the  dentate  margin,  forming  the  upper  limit  of  the  anus,  and  is 
continuous  at  its  outer  angle  with  the  adjacent  semilunar  valve.  The 
top  of  the  column  gradually  spreads  and  loses  ItseK  in  the  smooth  mu- 


FiG.  22. — Sho-wixg  Eeflectioj,'  of  PEEIT0^■^^3I  froii  Eectum  on  to  the  Pelvic  Walls, 
A,  B,  superior  pelvi-rectal  spaces :  C,  D,  ischio-rectal  fossae. 


ecus  membrane  of  the  rectal  wall.  They  vary  in  number  from  five  to 
twelve,  and  measure  from  base  to  apex  10  to  12  millimeters  (about  ^ 
an  inch)  (Fig.  T).  They  are  composed  of  mucous  and  submucous  tissue, 
and  contain,  according  to  Treitz,  some  muscular  fibers  which  act  in 
overcoming  the  eversion  which  takes  place  at  the  time  of  defecation. 

The  grooves  between  these  columns  gradually  deepen  from  above 
downward,  and  end  in  the  semilunar  valves.  Testut  (op.  cit.,  vol.  iv,  p. 
224)  states  that  in  these  grooves  are  found  irregular  elevations  caused 
by  dilatation  of  the  subjacent  veins. 

Semilunar  Valves,  Crypts  of  Morgagni,  Anal  Pockets. — The  rectal 
mucous  membrane  ends  below  in  an  irregular  festooned  border  com- 
posed of  small  folds  stretched  across  from  the  base  of  one  rectal  column. 


24  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

to  another,  their  concavity  being  directed  upward.  The  upper  border 
of  these  folds  comprises  the  so-called  ano-reetal  line.  Behind  these  folds 
the  membrane  dips  down  and  forms  little  pouches  of  variable  depths, 
which  are  called  the  crypts  of  Morgagni  or  anal  pockets.  The  folds 
themselves  are  termed  the  semilunar  valves  of  the  rectum.  The  epi- 
thelium covering  these  folds  gradually  changes  from  the  stratified  poly- 
hedral form  to  the  typical  columnar  epithelium  of  the  rectal  mucous 
membrane.  The  free  borders  of  the  valves  are  concave,  and  their  ex- 
tremities are  continuous  with  the  angles  of  the  rectal  columns.  They 
vary  in  number  from  five  to  twelve,  as  do  the  rectal  columns,  and  meas- 
ure in  width  from  6  to  12  millimeters.  In  depth  they  measure  upon  an 
average  3  to  5  millimeters.  In  some  cases  there  is  scarcely  any  depres- 
sion, while  in  others  a  veritable  sinus  exists  behind  the  valves  (Fig.  7,  B). 
They  are  said  to  be  deeper  and  more  apparent  in  early  life  than  in  old 
age,  but  they  are  often  quite  marked  in  adults.  They  are  almost  in- 
variably absent  at  the  anterior  and  posterior  commissures  of  the  rectum, 
but  there  is  generally  a  well-developed  crypt  upon  each  side  of  these 
points.  Those  in  the  anterior  circumference  are  less  accentuated  than 
those  situated  posteriorly.  This  fact  has  been  utilized  by  Ball  to  ex- 
plain why  fissures  occur  so  much  more  frequently  just  to  one  side 
of  the  posterior  anal  commissure  than  at  any  other  point.  Occasion- 
ally small  masses  of  iseeal  matter  or  foreign  bodies  are  arrested  in  these 
little  pockets  and  produce  much  local  and  reflex  irritation;  such  acci- 
dents are  comparatively  rare,  although  certain  irregular  practitioners 
have  made  great  capital  out  of  them,  and  ascribe  almost  every  dis- 
ease of  the  intestinal  canal  to  these  pockets.  The  function  of  these 
valves  is  practically  unknown.  They  have  been  considered  as  reservoirs 
for  the  mucus  or  lubricating  material  of  the  rectum,  but  frequent  ex- 
aminations at  periods  remote  from  defecation  have  failed  to  demon- 
strate any  accumulation  of  mucus  in  them.  Moreover,  their  epithelial 
lining  contains  no  mucus-producing  cells,  which  indicates  they  do  not 
secrete  the  material.  They  are  best  seen  in  the  living  subject  by  the  use 
of  a  conical  fenestrated  speculum,  into  which  is  introduced  a  small  lar- 
yngeal mirror.  On  the  margin  of  these  valves  are  seen  the  small  papillae 
which  have  been  described  in  connection  with  the  anal  canal. 

The  Valves  of  Houston  or  the  Rectal  Valves. — The  mucous  mem- 
brane of  the  rectum  above  the  crypts  of  Morgagni  is  thrown  into  irregu- 
lar horizontal  folds,  most  of  which  entirely  disappear  when  the  organ  is 
distended.  At  three  or  four  points  in  the  organ,  however,  these  folds 
become  more  prominent  when  the  gut  is  distended,  and  extend  out  into 
its  cavity  in  a  crescentic  form. 

Houston  (Dublin  Hospital  Eeports,  1830,  vol.  v,  p.  158)  first  de- 
scribed these  folds  as  valves  of  the  rectum.    Thev  vary  in  number  from 


EMBRYOLOGY,  ANATOMY,  AXD  PHYSIOLOGY 


25 


one  to  five.  Ordinarily  there  are  three,  termed  the  superior,  the  middle, 
and  inferior  valves  of  the  rectum.  The  middle  one  is  the  most  constant. 
It  arises  from  the  right  anterior  quadrant  of  the  rectal  wall  ahout  6  to  9 
centimeters  (3f  inches  to  3^^  inches)  above  the  margin  of  the  anus. 
Kohlrausch  described  this  fold  as  the  "  plica  transversalis  recti,"  but 
there  is  no  occasion  to  confuse  the  reader  by  introducing  any  new  nomen- 
clature. As  Testut  says,  the  name  originally  applied  to  them  by  Hous- 
ton "  is  rendered  sacred  by  long  usage."  As  described  by  Kohlrausch, 
Testut,  Otis,  and  others,  this  middle  valve  varies  in  height  according  to 
the  depth  of  the  peritoneal  cul-de-sac^  being  always  Just  below  the  latter. 
The  inferior  valve  is  located  upon  the  left  posterior  cpadrant  25  to 
30  millimeters  (1  to  1^  inches)  above  the  margin  of  the  anus^,  and  the  su- 
perior valve  is  located 
in  the  same  c[uadrant, 
slightly  more  to  the 
side,  at  9  to  11  centi- 
meters (3f  to  4|  inch- 
es) above  the  anus  (Fig. 
23).  At  the  juncture 
of  the  rectum  with  the 
sigmoid,  opposite  the 
third  sacral  vertebra, 
there  is  always  a  well- 
developed  fold  or  valve 
which  more  nearly  oc- 
cludes the  caliber  of 
the  organ  than  either 
of  the  others.  This 
valve  was  originally 
described  by  O'Beirne, 
who  attributed  to  it 
the  function  of  main- 
taining the  fgecal  mass 
in  the  sigmoid  flexure 
until  just  before  the 
crisis  of  defecation. 
It  is  situated  some- 
what anterior,  and  to 
the  right  or  left  side, 
according  to  the  di- 
rection of  the  flexure  of  the  sigmoid  upon  the  rectum.  It  is  more 
marked  in  those  cases  in  which  this  flexure  is  acute,  and  in  such  cases 
obscures  any  view  of  the  sigmoid  through  the  rectum. 


Fl&.    2S. — iLLrSTRATIXG   UsUAI,  LOCATION    OF    HoUSTON's 

Valves. 
"White  dotted  line  shows  height  to  which  the  peritoneal  cul- 
de-sac  is  raised  when  bladder  is  distended. 


26  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

The  rectal  valves  protrude  into  the  cavity  of  the  organ  to  various 
extents.  They  are  attached  to  the  wall  of  the  gut  from  one-third  to 
one-half  of  its  circumference ;  they  are  crescentic  in  shape,  and  present 
for  consideration  two  surfaces,  a  free  border,  a  base,  and  a  central  body. 
The  superior  surface  of  each  valve  apj^ears  as  a  smooth,  inclined  plane, 
slightly  depressed  in  its  center.  In  abnormal  conditions  this  depression 
may  become  quite  marked  and  capable  of  retaining  fsecal  or  foreign 
substances.  The  inferior  surface  of  the  valve  corresponds  to  the  supe- 
rior, being  more  or  less  convex,  according  to  the  concavity  of  the  latter, 
and  is  separated  from  it  by  the  mucous  membrane  and  tissues  which  com- 
pose the  body  of  the  valve.  The  free  borders  of  the  valves  are  crescentic 
in  shape,  clearly  defined,  and  directed  toward  the  cavity  of  the  rectum. 
In  the  normal  condition  they  are  usually  thin,  flexible,  and  easily  pushed 
aside.  Owing  to  the  arrangement  of  the  valves  at  different  levels,  these 
edges  overlapping  give  to  the  rectum,  when  dilated  and  viewed  through 
the  proctoscope,  an  appearance  somewhat  like  a  turbine  wheel  (Fig.  21). 
The  bases  of  the  valves  where  they  Join  the  rectal  wall  are  convex,  and 
considerably  thicker  than  the  free  border;  they  are  ordinarily  opposite 
one  of  the  grooves  in  the  external  rectal  wall,  as  shown  in  the  casts,  but 
this  arrangement  is  not  invariable.  Their  attachment  to  the  rectal  wall 
is  not  upon  a  horizontal  plane,  but  slightly  higher  on  one  side  than  on 
the  other,  thus  furnishing  a  sort  of  inclined  plane,  which  contributes  to 
the  easy  passage  of  the  faecal  material  over  them.  As  Houston  stated 
in  his  original  paper,  the  valves  consist  of  two  folds  of  mucous  mem- 
brane separated  by  cellular  tissue  and  muscular  fibers.  The  mucous 
membrane  covering  them  differs  in  no  wise  from  that  covering  the  rest 
of  the  rectum  in  normal  conditions.  The  structures  composing  the 
body  of  the  valves  between  the  layers  of  mucous  membrane  have  been 
minutely  described  by  Martin  (Philadelphia  Medical  Journal,  1899), 
Pennington  (Journal  of  the  American  Medical  Association,  Decem- 
ber, 1900),  and  more  recently  by  Testut  (Traite  d'anatomie  humaine, 
1901). 

Martin  claims  to  be  the  first  to  have  discovered  fibrous  tissue 
in  the  valves,  and  has  based  an  elaborate  theor}-  of  constipation  upon 
their  abnormalities.  Pennington  removed  a  large  number  of  recta  from 
children  and  adults  indiscriminately,  and  submitted  them  to  Prof.  Wil- 
liam A.  Evans  for  examination.  The  latter  demonstrated  the  presence 
of  these  valves  in  each  individual  case ;  he  located  the  most  prominent 
one  just  below  the  level  of  the  peritoneal  cul-de-sac,  and  the  next  most 
prominent,  "  that  which  contracted  the  caliber  of  the  gut  chiefly  "  at 
the  juncture  of  the  rectum  and  the  sigmoid,  just  as  we  have  described 
above.  The  muscularis  mucosa  M-as  found  to  be  more  prominent  in  the 
valves  than  elsewhere ;  the  submucosa  was  composed  of  loosely  arranged 


EMBRYOLOGY,  ANATOMY,  AND  PHYSIOLOGY 


27 


connective  tissue,  quite  vascular,  devoid  of  lymph  elements,  and  almost 
twice  as  thick  as  elsewhere  in  the  rectal  wall.  The  circular  muscular 
coat  was  found  to  dip  well  into  the  valves,  and  measured  from  two  to 


Fig.  24.— Infeeioe  and  Middle  Valves  of  Houstok. 
As  seea  through  the  proctoscope. 

four  times  as  thick  here  as  elsewhere.    The  longitudinal  muscular  fibers 
were  found  to  be  very  irregular  in  their  behavior,  sometimes  passing 


28 


THE  ANCS,  RECTUM,  AND   PELVIC   COLON 


over  the  depressions  formed  by  the  entrance  of  the  circular  fibers  into  the 
valves,  and  sometimes  dipping  into  these  grooves.  This  is  in  harmony 
with  the  observations  of  Lamier  referred  to  in  describing  the  longi- 
tudinal muscular  coat  of  the  rectum. 

Evans  describes  numerous  unusual  conditions  and  abnormal  develop- 
ments in  the  valves.  AYhile  these  minute  studies  of  the  anatomical  struc- 
ture are  interesting,  they  have  no  practical  value  for  the  surgeon  beyond 
confirming  the  statements  of  Houston  that  the  sti"uctures  are  not  simple 
mucous  folds,  but  true  valves  composed  of  mucous  membrane,  cellular 
and  fibrous  tissue,  and  possessed  of  circular  muscular  fibers.     It  is  a 

singular  fact  that  in  none  of  the 
examinations  thus  far  made  has  it 
been  shown  that  the  peritonasum 
dipped  into  the  groove  at  the  base 
of  the  valve.  The  illustration  (Fig. 
25)  shows  the  extent  to  which  these 
valves  may  develop,  together  with 
their  oblique  attachment  to  the  rec- 
tal wall. 

The  function  of  these  valves  is 
to  support  the  ftecal  mass  in  its 
passage  through  the  rectal  canal, 
and,  being  so  arranged  as  to  present 
to  the  mass  an  inclined  plane  pass- 
ing circularly  around  the  rectum, 
they  impart  to  it  a  rotary  or  cork- 
screw motion  by  which  it  is  depos- 
ited from  one  valve  upon  the  upper 
surface  of  the  valve  below  until 
it  reaches  the  anus.  Martin  and 
Pennington  have  experimented  by 
introducing  lubricated  cotton-balls 
into  the  sigmoid  flexure,  and  have 
observed  their  passage  downward 
through  the  rectum  by  the  aid  of 
the  proctoscope.  They  state  that 
the  balls  slip  from  the  sigmoid  into  the  rectum  and  lodge  against 
the  first  valve;  they  are  then  carried  by  a  rotary  motion  downward 
and  forward  to  the  middle  valve,  and  then  by  the  same  motion  they 
are  deposited  posteriorly  upon  the  lower  valve,  and  finally  from  this 
valve  upon  the  internal  sphincter  or  into  the  mouth  of  the  instrument 
through  which  they  were  observed  during  the  process.  Thus,  appar- 
ently, gross  and  microscopical  anatomy  and  clinical  observations  all  tend 


iiG.  25. — Abxormal  Development  of 

Valves  of  Houstox. 

Drawn  from  specimen  furnished  the  author 

by  Dr.  J.  K.  Pennington. 


EMBRYOLOGY,  ANATOMY,  AND    PHYSIOLOGY 


29 


to  confirm  more  and  more  Houston's  original  claims  as  to  the  existence 
and  functions  of  these  valves. 

Vascular  Supply. — Arteries. — Tlie  rectum  receives  its  blood  supply 
from  four  sources  :  the  superior,  middle,  and  inferior  li^emorrhoidal,  and 
the  middle  sacral  arteries. 

The  superior  hcemorrlioidal  artery  is  the  terminal  division  of  the  in- 
ferior mesenteric  which  has  its  origin  in  the  aorta  just  below  the  nephritic 
artery.  It  descends  in  front  and  slightly  outside  of  the  right  internal 
iliac,  and  is  embedded  in  the  two  folds  of  the  mesentery.  At  about  the 
level  of  the  promontory  of  the  sacrum  it  gives  off  the  sigmoidal  artery 
(Fig.  26)  which  supplies  the  lower  portion  of  the  sigmoid;  it  passes 


Fig.  26. — Ixferior  Mesexteeic  Aeteet  giving  off  Sigmoidal   Bhaxch  A^*D  TEEiiiXATixG 
IX  SuPEEioE  IIj:moeehoidal. 

Distribution  of  latter  to  the  rectum  and  its  anastomosis  with  middle  hiemorrhoidal  artery. 


downward  between  the  folds  of  the  mesorectum,  and  divides  about  the 
level  of  the  second  piece  of  the  sacrum  into  two,  sometimes  three  divi- 
sions, which  pass,  one  upon  the  right  and  one  upon  the  left  side  of  the 
rectum;  the  left  branch  is  distributed  to  that  side  and  to  the  anterior 
surface  of  the  gut,  the  right  branch  is  distributed  to  the  right  side  and 
posterior  surface  of  the  gut.  About  4-|  inches  above  the  margin  of  the 
anus  these  vessels  penetrate  the  muscular  wall  of  the  gut,  after  which 
they  divide  into  numerous  branches,  and  descend  to  the  lower  limits  of 
the  rectum,  where  they  terminate.  The  trunks  of  the  vessels  run  more 
or  less  parallel  with  the  long  axis  of  the  gut,  and  their  capillary  divi- 


30  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

sions  pass  around  the  intestine,  freely  anastomosing  with  one  another. 
They  also  anastomose  with  branches  from  the  middle  hiemorrhoidal  and 
middle  sacral  arteries. 

The  middle  hcemorrhoidaJ  artery  is  extremely  variable  in  its  origin. 
It  generally  arises  from  the  hypogastric  artery,  but  may  arise  from  the 
internal  iliac  or  the  prostatic.  It  is  situated  above  the  levator  ani  mus- 
cle, and  passes  through  the  superior  pelvi-rectal  spaces,  distributing  some 
branches  to  the  anterior  surface  of  the  rectum,  to  the  seminal  vesicles 
and  prostate  in  men,  and  to  the  vagina  in  women.  It  supplies  the  leva- 
tor ani  muscle,  and  furnishes  a  distinct  anastomotic  circulation  with  the 
superior  hsmorrhoidal  artery,  which  in  cases  of  injury  to  the  latter  ves- 
sel would  afford  an  adequate  circulation  to  the  lower  end  of  the  rectum. 

The  inferior  }i(emorrhoidal  artery  arises  from  the  internal  pudic  and 
crosses  the  ischio-rectal  fossa  obliquely  from  the  posterior  portion  of 
its  outer  wall;  it  divides  into  a  number  of  branches  which  supply  the 
lower  portion  of  the  levator  ani,  the  external  and  internal  sphincters, 
the  skin,  and  superficial  fascia  around  the  anus.  The  branches  of  one 
side  anastomose  with  those  of  the  other,  and  with  branches  of  the  mid- 
dle haemorrhoidal  artery.  They  also  anastomose  in  a  very  mild  degree 
with  the  lowest  branches  of  the  superior  hsemorrhoidal  artery. 

The  middle  sacral  artery  arises  from  the  posterior  portion  of  the 
aorta  at  its  bifurcation,  and  descends  along  the  middle  line  in  front 
of  the  sacrum,  terminating  in  a  minute  branch  which  supplies  the  gland 
of  Luschka;  it  gives  off  branches  which  pass  through  the  cellular  tissue 
to  supply  the  posterior  surface  of  the  rectum.  Its  branches  anastomose 
with  the  branches  of  the  superior  hsemorrhoidal  and  the  lateral  sacral 
arteries. 

Veins. — The  veins  of  the  rectum  correspond  in  name  and  course  to 
the  arteries,  but  they  return  the  blood  through  two  entirely  different 
channels — viz.,  the  portal  vein  and  the  inferior  vena  cava.  The  internal 
or  superior  hgemorrhoidal  veins  collect  the  blood  from  the  rectum  proper 
and  empty  it  through  the  mesenteric  vein  into  the  portal  circulation. 
The  middle  and  external  hfemorrhoidal  veins  (Fig.  27)  and  the  middle 
sacral  veins  collect  the  blood  from  the  external  surfaces  of  the  rectum 
and  anus  and  empty  it  into  the  general  circulation  through  the  vena 
cava.  The  internal  hgemorrhoidal  plexus  forms  the  venous  supply  of  the 
rectum  proper.  The  ano-rectal  line  marks  the  beginning  of  these  veins 
above  and  the  external  veins  below.  This  line,  as  Otis  has  happily  said, 
provides  a  sort  of  watershed  between  the  two  circulations  of  such  low 
altitude  that  under  certain  conditions  it  does  not  interpose  a  sufficient 
barrier  to  prevent  an  intermingling  of  the  two  streams.  The  two  sys- 
tems are  connected  at  this  point  through  anastomotic  branches  which 
are  so  narrow  in  early  life  as  to  be  almost  imperceptible. 


EMBRYOLOGY,   ANATOMY,    AND   PHYSIOLOGY 


31 


Cripps  {op.  cit.,  p.  26)  says  he  has  demonstrated  that  the  internal 
hasmorrhoidal  plexus  can  not  be  injected  through  the  iliac  veins,  but 
it  can  be  injected  through  the  inferior  mesenteric  vein,  and  the  blood 
will  not  pass  on  into  the  external  veins,  so  that  if  any  communication 
exists  between  the  two  systems  it  must  be  protected  by  valves.  Quenu 
and  Testut  have  both 
demonstrated  the  ex- 
istence of  valves  in 
these  anastomotic 
veins  in  the  adult,  and 
thus  in  part  corrobo- 
rate the  views  of 
Cripps,  but  they  state 
that  the  inferior  hem- 
orrhoidal plexus  can 
be  injected  through 
the  inferior  mesenteric 
veins.  The  author  has 
demonstrated  the  fact 
that  the  external  plex- 
us can  be  injected  from 
the  inferior  mesen- 
teric veins  in  old  sub- 
jects who  have  suffered 
from  constipation  and 
hemorrhoidal  disease. 
Indeed,  the  communi- 
cation betn^een  these 
two  systems  is  often 
apparent  to  the  naked 
eye  in  operations  upon 

mixed  haemorrhoids,  and  it  is  no  longer  necessarv  in  the  light  of  such 
positive  facts  to  further  discuss  this  question  of  anastomosis. 

Just  above  the  ano-rectal  line  in  the  submucous  tissue  there  are 
numerous  small  venous  sacs  or  pools  (Fig.  28),  bulbous  or  elliptical  in 
shape,  and  each  about  the  size  of  a  grain  of  wheat.  These  little  pools 
surround  the  rectum,  some  at  a  higher  and  some  at  a  lower  level,  and 
practically  form  the  beginning  of  the  internal  hsemorrhoidal  plexus. 
Buret  (Archiv.  gen.  de  med.,  December,  1879  and  1885)  states  that 
these  little  pools  are  arranged  like  clusters  of  grapes  in  the  columns 
of  Morgagni.  The  dissection  made  by  the  writer,  however,  shows  that 
they  entirely  surround  the  rectum,  and  are  not  particularly  aggregated 
in  the  columns.     From  these  pools  the  small  veins  proceed  in  all  direc- 


FiG.    27. — External  a2sT)   Middle    H.emorehoidal   Veixs 

ARISING    FROM    THE     AnaL     CaI»AL    AND    LoWER    ExD     OF 

THE  Eectum;  also  Branches  running  upward  to  form 
Superior  H^uorrhoidal  A^eins. 


32 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


tions  to  form  an  intricate  network  of  vessels  surrounding  the  rectum. 
Above  the  margin  of  the  internal  sphincter  they  unite  to  form  larger 
trunks,  which  approach  the  arteries,  and  with  them  penetrate  the  mus- 
cular wall  of  the  gut ;  the  venous  trunks  unite  above  this  point  to  form 


Fig.  28.— Vascular  Supply  of  Lower  End  of  Rectum  (Partly  Schematic). 
Showing  venous  pools  in  which  internal  luemorrhoidal  plexus  originates. 

the  inferior  mesenteric  vein  which  empties  into  the  portal  circulation. 
These  veins  are  without  valves. 

Verneuil  has  advanced  the  ingenious  theory  that  the  contraction 
of  the  longitudinal  muscular  fibers,  at  the  points  where  the  vessels  per- 
forate the  rectal  wall,  serves  to  supply  the  place  of  the  valves,  and  inci- 


EMBRYOLOGY,  ANATOMY,  AXD   PHYSIOLOGY  33 

dentally  he  claims  that  the  spasms  of  these  muscles^  causing  obstruction 
in  the  veins,  have  a  potent  influence  in  the  production  of  internal  haemor- 
rhoids. It  is  impossible  to  confirm  or  deny  this  theory,  as  the  facts  are 
not  demonstrable. 

The  middle  hsemorrhoidal  veins  arise  from  the  anterior  surface  of 
the  rectum  above  the  levator  ani  muscle,  the  seminal  vesicles  and  the 
prostate  in  men,  and  the  vaginal  wall  in  women.  The  capillaries  unite 
into  larger  trunks  and  follow  the  course  of  the  arteries  through  the 
pelvi-rectal  spaces,  and  empty  sometimes  into  the  hypogastric  and  some- 
times into  the  ischiatic  veins,  but  always  finally  into  the  general  circula- 
tion through  the  vena  cava. 

The  external  hsemorrhoidal  veins  originate  in  the  small  anastomotic 
capillaries  in  the  anal  canal;  they  become  more  or  less  dilated  as  they 
pass  outward  over  ihe  border  of  the  external  sphincter,  but  immediately 
narrow  down  and  unite  with  the  subcutaneous  capillaries  of  this  region 
to  form  trunks  which  empty  into  the  external  pudic  vein,  through  which 
they  are  connected  with  the  general  circulation. 

The  Nerve  Supply  of  the  Anus  and  Rectum. — The  anus  and  rectum 
receive  their  nerve  supply  both  from  the  great  sympathetic  and  cerebro- 
spinal systems.  The  rectum  proper  is  largely  supplied  by  the  sympa- 
thetic system;  it  receives  branches  from  the  mesenteric,  sacral,  and 
hypogastric  plexuses.  It  also  receives  filaments  from  the  third,  fourth, 
and  fifth  sacral  nerves.  The  mucous  membrane  of  the  rectum  becomes 
less  and  less  sensitive  from  below  upward,  thus  indicating  the  absence 
of  sensitive  fibers  in'  this  portion  of  the  gut,  a  fact  which  has  been  cor- 
roborated by  microscopic  and  anatomical  research. 

The  nerve  supply  of  the  muscular  apparatus  of  the  anus  and  rectum 
arises  from  the  intricate  plexuses  formed  by  the  second,  third,  fourth, 
and  fifth  sacral  nerves  (Fig.  29).  The  filaments  from  these  nerves 
unite,  separate,  and  reunite  so  often  that  it  is  impossible  to  determine 
the  exact  origin  of  any  of  the  final  trunks  of  distribution.  iVccording 
to  Morestin,  Langley,  Anderson,  and  Testut,  the  levator  ani  receives  its 
three  filaments  from  the  third  and  fourth  sacral  nerves.  The  first  two 
filaments  are  distributed,  one  to  the  posterior  or  ischio-coccygeal  por- 
tion, and  the  other  to  the  anterior  or  levator  ani  proper;  the  third  fila- 
ment passes  beneath  the  muscle  and  gives  off  branches  to  its  lower  sur- 
face, and  passes  onward  to  supply  some  small  filaments  to  the  superficial 
surface  of  the  external  sphincter. 

The  external  sphincter  muscle  receives  its  nerve  supply  from  three 
sources;  two  filaments  from  the  branches  formed  by  the  third,  fourth, 
and  fifth  sacral  nerves  extend  transversely  across  the  ischio-rectal  fossa, 
and  distribute  themselves  to  the  middle  portion  of  the  muscle  and 
to  the  perianal  cutaneous  surfaces;  a  filament  which  comes  off  from  the 
3 


34 


THE  AXUS,  RECTUM.  AND  PELVIC  COLON 


internal  pudic,  just  before  its  division  into  terminal  branches,  sup- 
plies the  anterior  portion  of  the  muscle,  and  is  called  the  anterior 
sphinderian  nerve;  while  a  filament  coming  off  from  the  fifth  and 
sixth  sacral  nerves  passes  down  into  the  hollow  of  the  sacrum  between 
the  levator  ani  muscle  and  the  recto-coccvgeus  ligament,  and  finally 

reaches  the  posterior 
superficial  surface  of 
the  external  sphincter. 
Morestin  calls  this  the 
lesser  sphincterian 
nerve.  All  these  fila- 
ments possess  both 
sensitive  and  motor 
fibers,  and  with  them 
are  distributed  fila- 
ments of  the  sympa- 
thetic nerve.  The  cen- 
tral origin  of  the  nerve 
supply  of  the  anus  and 
rectum  is  said  to  be 
located  about  the  level 
of  the  first  lumbar  ver- 
tebra. This  center  is 
practically  the  same  as 
that  of  the  genito-uri- 
nary  apparatus,  which 
fact  accounts  in  a  large 
measure  for  the  vari- 
ous reflexes  between 
the  two  systems.  The 
inhibitory  center  of 
this  nerve  supply  is 
situated  in  the  brain,  but  the  exact  location  is  unknown. 

Lymphatics  of  the  Anus  and  Rectum. — The  lymphatics  of  the  anus 
and  rectum  are  very  difficult  to  demonstrate  by  dissection.  Occasionally 
cases  have  been  found  in  which  the  vessels  and  glands  have  become  in- 
flamed and  thickened,  and  thus  the  seat  and  course  of  these  particular 
vessels  have  been  traced.  Quenu  (Bull,  de  la  Societe  anatomic,  Paris, 
1893,  p.  399)  has  shown  that  these  organs  are  supplied  with  three  sets  of 
lymphatics  practically  corresponding  to  the  arterial  supply.  The  sacral 
or  superior  plexus  of  the  lymphatics  originates  in  the  submucous  and  mu- 
cous portions  of  the  middle  and  upper  rectum  posteriorly.  They  follow 
the  course  of  the  vessels,  the  lymphatic  ganglia  lying  in  close  apposition 


Fig.  29. — Spinal  Nerves  of  the  Rectim  and  Anus. 


EMBRYOLOGY,   ANATOMY,   AND   PHYSIOLOGY 


35 


Fig.  30. — Lymphatics  of  Anal  axd  Perianal  Region. 


with  the  hemorrhoidal  veins.  Between  the  rectum  and  the  anterior 
surfaces  of  the  sacrum  and  coccyx  is  found  a  chain  of  lymphatics  which 
extends  upward  in  the 
cellular  tissue  between 
the  folds  of  the  mes- 
entery, and  is  thus 
connected  with  the 
prevertebral  lymphat- 
ic system. 

The  middle  h^em- 
orrhoidal  vessels  are 
also  accompanied  by  a 
chain  of  lymphatics 
which  follows  their 
course  and  ends  in  the 
hypogastric  lymphatic 
plexus.  These  lym- 
phatics originate  in 
the  anterior  portion 
of    the    rectum,    and, 

passing  outward  above  the  levator  ani  muscle  between  the  rectum  and 
the  prostate  in  the  male  and  along  the  circular  vaginal  veins  in  the 
female,  they  finally  reach  their  destination  in  the  hypogastric  plexus. 

Quenu  says  it  appears 
from  his  dissections 
that  the  middle  por- 
tion of  the  rectum  is 
connected  with  the 
lymphatics  of  both 
the  sacral  and  hypo- 
gastric plexuses. 

The  lymphatics  of 
the  anal  and  perianal 
region  are  very  nu- 
merous. They  are 
connected  by  anasto- 
motic branches  with 
the  lower  lymphatics 
of  the  rectum.  They  do 
not  follow  the  course 
of  the  external  hffimor- 


FiG.  31. 

rhoidal 
passing 


-Showing  Connection  between  Perianal  and 
Inguinal  LviiPHATics. 


veins  very  closely,  but  ramify  beneath  the  skin,  the  chief  branches 
forward  and  upward  between  the  scrotum  and  the  thigh,  and 


36  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

finally  unite  with  the  inguinal  lymphatics  (Figs.  30,  31).  It  has  not  been 
demonstrated  whether  or  not  this  chain  is  directly  connected  with  the 
inferior  chain  of  the  lymphatics  below  Poupart's  ligament.  The  im- 
portance of  the  lymphatic  system  about  the  anus  and  rectum  will  be 
appreciated  when  we  come  to  study  the  subject  of  infectious  and  malig- 
nant diseases  of  these  organs.  Clinical  experience  corroborates  the  ana- 
tomical studies  of  Deaver,  Quenu,  and  Moreau  (Bull,  de  la  Societe  de 
biologic,  1894,  p.  812)  with  regard  to  the  origin  and  distribution  of  the 
lymphatic  system. 

Retro-rectal  and  Superior  Pelvi-rectal  Spaces. — To  comprehend  the 
relations  of  the  rectum  one  must  thoroughly  understand  the  cellular 
spaces  surrounding  it.  That  portion  of  the  organ  below  the  peritoneal 
attachment  and  above  the  levator  ani  is  surrounded  in  its  entire  course 
by  a  cellulo-fibrous  layer,  in  which  ramify  the  blood-vessels,  nerves,  and 
lymphatics  before  they  penetrate  the  walls  of  the  organ.  This  layer 
forms  a  complete  sheath  to  the  rectum,  and  extends  from  the  perito- 
neal fold  down  to  the  superior  surface  of  the  levator  ani  muscle.  It  is 
longer  behind  than  in  front.  The  fibrous  portion  of  this  sheath  is  out- 
side of  the  cellular,  and  originates  in  the  fascije  lining  the  true  pelvis; 
it  passes  off  from  the  pelvis  in  a  double  layer  at  the  points  where  the 
lateral  sacral  arteries  diverge,  and  the  inner  layer  attaches  itself  more 
or  less  firmly  to  the  sides  of  the  rectum  at  about  the  middle  of  its  cir- 
cumference. These  folds  represent  the  lateral  ligaments  of  the  pelvic 
rectum,  as  described  b}^  Jonnesco  and  Ombredanne,  and  are  the  chief 
supports  of  this  portion  of  the  organ.  The  outer  layer  of  this  fascia 
proceeds  along  the  border  of  the  sacrum  and  is  attached  to  this  bone. 
Between  these  layers  posteriorly,  separating  the  rectum  from  the  sacrum, 
is  a  comparatively  thick  cellulo-vascular  area  which  extends  to  the  su- 
perior fascia  of  the  levator  ani  below,  and  upward  between  the  layers 
of  the  mesorectum,  thus  becoming  continuous  with  the  prevertebral 
cellular  layer  of  the  abdominal  cavity  (Fig.  32).  This  cellular  space  is 
termed  the  retro-rectal  space,  and  has  been  compared  by  Ombredanne  to 
the  prevesical  space  of  Eetzius. 

Anteriorly  the  rectum  is  also  surrounded  by  a  cellular  space  above 
the  levator  ani  muscles,  which  is  separated  from  the  retro-rectal  space 
by  the  latero-rectal  ligaments  which  we  have  just  described.  This  space 
separates  the  rectum  from  the  bladder,  prostate,  and  seminal  vesicles  in 
men,  and  from  the  broad  ligaments  and  uterus  in  women.  It  is  bounded 
in  front  by  the  prostato-peritoneal  aponeurosis,  which  contains  a  cer- 
tain number  of  muscular  fibers.  This  aponeurosis  is  closely  attached  to 
the  prostate,  passes  loosely  over  the  seminal  vesicles  backward,  and  is 
attached  to  the  sides  of  the  rectum  along  with  the  latero-rectal  liga- 
ments.   It  is  also  attached  to  the  anterior  wall  of  the  rectum,  thus  divid- 


EMBRYOLOGY,  ANATOMY,  AND  PHYSIOLOGY 


37 


ing  this  anterior  cellular  space  into  two  portions.  The  spaces  thus 
formed  are  more  closely  connected  with  the  genito-urinary  apparatus 
than  with  the  rectum,  although  they  form  the  anterior  boundary  to  the 

latter    organ.       They 

are  known  as  the  su-  '  '  /  4.iaU,.Z.  ■  -'^■^e^- 
perior  pelvi  -  rectal 
spaces  (Fig.  22).  It  is 
in  them  that  abscesses 
originating  in  the 
prostate,  seminal  vesi- 
cles, uterus,  and  broad 
ligament  often  devel- 
op. It  is  not  pretend- 
ed that  the  division 
between  the  retro- 
rectal and  pelvi-rectal 
spaces  is  so  firm  that 
it  can  not  be  broken 
down,  or  that  abscess- 
es developing  in  one 
may  not  penetrate  the 
other.  As  a  rule,  how- 
ever, those  developing 
in  the  retro-rectal 
space  will  burst  into 
the  ischio-rectal  fossa 
or  burrow  out  through 
the  obturator  foramen 
before     they     invade 

the  anterior  spaces;  and  those  developing  in  the  superior  pelvi-rectal 
spaces  will  burrow  upward  and  forward,  often  opening  in  the  inguinal 
region  or  through  the  abdominal  wall  before  they  invade  the  retro-rectal 
space.  These  spaces  are  separated  from  the  ischio-rectal  fossse  by  the 
levator  ani  muscle  and  its  limiting  fascise.  The  ischio-rectal  fossse 
which  surround  the  anus  and  lower  portion  of  the  rectum  have  been 
described  in  the  preceding  pages. 

The  Relations  of  the  Rectum. — The  rectum  is  in  relation  at  its  dif- 
ferent levels  with  the  various  organs  and  tissues  of  the  pelvic  cavity. 
The  lower  or  prostatic  portion  is  in  relation  anteriorly  with  the  prostate 
and  membranous  urethra  in  men,  and  in  women  with  the  vaginal  wall. 
As  the  rectum  turns  backward  at  its  lower  end,  and  the  uro-genital  or- 
gans forward,  the  space  left  between  the  two  comprises  the  uro-genital 
triangles  or  perineal  body.     Laterally  this  lower  portion  of  the  rectima 


Fig.  32. — Exaggerated  Eetro-rectal  Cellular  Space. 


38  THE   ANUS.   RECTUM,  AXD   PELVIC   COLOX 

is  in  relation  vrith  the  external  sphincter,  the  levator  ani  muscle,  and  the 
limiting  fascife  of  the  ischio-rectal  fossae.  Posteriorly  it  is  in  relation 
with  the  levator  ani,  the  external  sphincter,  and  the  recto-coccygeus 
muscles,  and  with  the  fibro-cellular  tissue  separating  it  from  the  coccyx 
and  the  gland  of  Luschka. 

The  upper  or  peritoneal  portion  of  the  rectum  is  in  relation  ante- 
riorly with  the  bladder  and  upper  portion  of  the  prostate  and  seminal 
vesicles  in  men,  and  with  the  vagina  in  women.  Above  these  points  is 
the  peritoneal  cul-de-sac  called  the  prostato-vesical  cul-de-sac  in  men, 
and  Douglas's  pouch  in  women.  These  culs-de-sac  contain  the  sig- 
moid flexure,  loops  of  the  small  intestine,  and  various  abdominal  organs, 
as  has  been  already  described.  The  anterior  surface  of  the  rectum  above 
this  point  is  therefore  in  relation  with  these  organs. 

Laterally,  l^elow  the  reflection  of  the  peritonaeum  upon  the  sides  of 
the  pelvis,  the  rectum  is  surrounded  by  a  cellular  layer  containing  the 
hypogastric  nerves  and  the  lateral  sacral  arteries,  which  pass  outside  of 
it  in  the  fibrous  sheath.  Posteriorly  this  portion  of  the  rectum  is  sepa- 
rated from  the  sacrum  and  coccyx  by  the  cellular  tissue,  occupying  the 
retro-rectal  space.  On  each  side  posteriorly  it  is  in  contact  up  above 
with  the  sacral  plexus  and  sympathetic  ganglia,  and  also  with  the  fascial 
origin  of  the  pyramidal  muscles.  At  its  lower  end  it  comes  in  contact 
with  the  gland  of  Luschka.  It  is  important  to  observe  that  the  organ, 
while  related  to  the  pelvic  contents,  is  not  so  closely  attached  to  any  of 
them  that  it  can  not  be  removed  without  injury  to  vital  parts. 

The  Supports  of  the  Rectum. — According  to  the  division  which  we 
have  adopted  the  rectum  is  practically  a  fixed  organ.  It  may  vary  in 
caliber  and  shape  according  to  various  circumstances,  but  unless  dis- 
placed by  pathological  conditions,  it  remains  always  in  one  position.  It 
is  held  in  this  position  by  active  and  passive  supports.  The  active  sup- 
ports are  found  in  the  muscular  fibers  of  the  gut  itself,  in  the  external 
sphincter,  levator  ani,  and  recto-coccj'geus  muscles.  The  passive  sup- 
ports consist  of  connective-tissue  fibers,  which  bind  the  rectum  to  the 
surrounding  organs  or  tissues,  in  elastic-tissue  bundles  formed  by  the 
peritoneal  fold,  and  finally  b}^  the  blood-vessels  which  supph^  the  organ. 

The  chief  support  of  the  lower  portion  of  the  rectum  comes  from 
the  levator  ani  and  external  sphincter  muscles,  together  with  its  fibrous 
attachments  to  the  coccyx,  prostate,  or  vagina.  The  middle  portion  is 
held  in  position  by  the  lateral  fibrous  sheaths,  which  pass  off  from 
the  sacrum  and  ilium  along  the  course  of  the  lateral  sacral  arteries.  The 
superior  portion  is  held  in  position  by  the  peritoneal  folds  which  pass 
from  the  organ  and  are  reflected  upon  the  bladder  or  uterus  in  front, 
upon  the  pelvic  walls  laterally,  and  unite  posteriorly  to  form  the  meso- 
rectum  and  attach  the  organ  to  the  anterior  surface  of  the  sacrum.    This 


EMBRYOLOGY,  ANATOMY,  AND  PHYSIOLOGY  39 

part  of  the  organ  also  receives  a  certain  amount  of  support  from  the  infe- 
rior mesenteric  arteries  and  the  fibrous  sheaths  which  surround  them. 

The  Sigmoid  Flexure  or  Pelvic  Colon. — This  loop  of  the  large  intes- 
tine, termed  also  the  omega  loop,  and  by  French  writers  the  pelvic 
colon,  begins  above  at  the  termination  of  the  descending  colon  near  the 
outer  border  of  the  left  psoas  muscle,  and  comprises  all  that  portion 
of  the  intestinal  canal  between  this  point  and  the  upper  termination  of 
the  rectum  opposite  the  third  sacral  vertebra. 

As  ordinarily  measured  m  situ,  it  is  about  19  inches  in  length,  but 
when  removed  from  the  body  and  stretched  out  upon  its  mesentery  this 
length  is  considerably  increased. 

It  originates  in  the  left  iliac  fossa,  passes  downward  for  2  inches 
parallel  to  the  external  border  of  the  psoas  muscle;  it  then  crosses 
transversely  to  pass  into  the  pelvic  ca;vity,  which  it  occupies  for  the 
greater  portion  of  its  extent;  passing  across  this  cavity  from  left  to 
right,  and  slightly  upward,  it  reaches  the  lower  margin  of  the  right  iliac 
fossa  •  from  this  point  it  passes  downward,  backward,  and  inward  along 
the  anterior  surface  of  the  sacrum  to  its  junction  with  the  rectum.  It  is 
attached  to  the  posterior  wall  of  the  abdomen  and  pelvis  by  a  peritoneal 
fold  called  the  mesosigmoid,  which  is  continuous  with  the  mesocolon,  but 
is  much  longer  than  the  latter,  thus  giving  the  sigmoid  greater  mobility 
than  any  other  portion  of  the  large  intestine.  This  mobility  explains  the 
great  variation  in  its  situation,  direction,  and  relations,  as  described  by 
different  authors. 

The  sigmoid  is  divided  into  four  portions  :  The  first  portion  is  verti- 
cal; the  second  is  transverse;  the  third  forms  a  long  loop  with  its  eon- 
cavity  directed  upward  when  the  sigmoid  occupies  the  pelvis,  and  down- 
ward when  it  is  lifted  up  into  the  abdomen;  the  fourth  is  irregularly 
curved,  and  descends  into  the  hollow  of  the  sacrum,  downward,  backward, 
and  inward. 

From  this  description  it  will  appear  that  the  sigmoid  joins  the  rec- 
tum from  the  right  side  of  the  pelvis  instead  of  the  left,  as  is  held  by 
most  authors.  For  a  long  time  the  author  has  taught  and  demonstrated 
the  fact  that  the  intestine  at  the  juncture  of  the  rectum  and  sigmoid 
turns  to  the  right  quite  as  frequently  as  to  the  left.  The  anatomical  and 
clinical  studies  of  Testut,  Schifferdecker,  Jonnesco,  Treves,  and  others 
prove  that  this  is  in  reality  the  most  frequent  disposition. 

The  walls  of  the  sigmoid  are  composed  of  four  layers,  the  mucous, 
submucous,  muscular,  and  serous. 

The  Mucous  and  Submucous  Layers. — The  mucous  and  submucous 
layers  differ  in  no  wise  from  those  of  the  rectum,  except  that  the  solitary 
follicles  are  less  frequent,  and  the  membrane  in  its  entirety  is  not  quite 
so  thick  as  in  the  lower  organ. 


40  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

The  Muscular  Layer. — The  muscular  layer  consists  of  circular  and 
longitudinal  fibers.  The  circular  fibers  are  distributed  around  the  sig- 
moid much  more  equably  than  around  the  rectum.  While  there  are  cer- 
tain points  or  flexures  in  the  gut  where  aggregations  of  these  fibers  take 
place  upon  one  side,  these  aggregations  never  completely  surround  the 
gut,  nor  are  they  ever  so  marked  as  to  produce  any  idea  of  a  sphincter 
muscle. 

The  longitudinal  fibers,  arranged  at  first  in  three  bands  as  in  the  de- 
scending colon,  gradually  assume  the  form  of  an  anterior  and  a  posterior 
band,  which  spread  out  as  they  approach  the  recto-sigmoidal  juncture, 
and  form  a  more  or  less  complete  layer  around  the  gut. 

Serous  Layer. — The  peritoneal  layer  of  the  sigmoid  flexure  surrounds 
the  gut  similarly  to  that  of  the  small  intestine,  and  its  folds,  coming  in 
contact  with  each  other  posteriorly,  form  the  mesosigmoid  or  ilio-pelvic 
mesocolon.  This  mesentery  is  quite  short  in  its  iliac  portion,  but  rapidly 
becomes  longer,  reaching  its  maximum  about  the  middle  portion  of  the 
pelvic  loop,  where  it  again  grows  shorter,  and  finally  terminates  at  the 
juncture  of  the  sigmoid  with  the  rectum.  The  lower  portion  of  this 
mesentery,  as  already  stated,  is  called  the  mesorectum. 

The  line  of  insertion  of  the  mesosigmoid  into  the  pelvic  and  abdom- 
inal walls  may  be  described  as  follows :  Beginning  above  at  the  exter- 
nal border  of  the  psoas  (Fig.  33),  it  follows  this  line  downward  to  a 
point  about  2  to  3  centimeters  (f  to  ly\  inch)  above  the  crural  arch; 
here  it  crosses  the  psoas  muscle  from  left  to  right,  and  turning  upon 
itself  follows  the  internal  border  of  the  muscle  upward  and  inward  as 
high  as  the  fifth  or  fourth  lumbar  vertebrae,  where  it  again  bends  down- 
ward and  inward,  crossing  the  right  common  iliac  artery,  and  reaches  the 
median  line  on  a  level  with  the  sacro-vertebral  Juncture.  From  this 
point  it  descends  in  the  median  line  as  far  as  the  third  sacral  vertebra, 
where  it  ends.  Sometimes  the  attachment  of  the  mesosigmoid  extends 
across  the  middle  line,  passing  over  the  fifth  lumbar  vertebra  almost  to 
the  internal  border  of  the  right  psoas  muscle,  and  then  turns  downward 
and  inward,  following  the  anterior  surface  of  the  sacrum  to  the  begin- 
ning of  the  rectum.  Between  the  two  layers  of  this  fold  there  is  a  thin, 
cellular  layer,  through  which  the  blood-vessels,  nerves,  and  lymphatics 
of  the  intestine  pass. 

In  a  certain  number  of  cases  the  mesosigmoid,  after  turning  down- 
ward at  the  lumbosacral  juncture,  passes  toward  the  left  until  it  reaches 
the  sacro-ischiatic  symphysis,  and  then  turns  backward  toward  the 
median  line  of  the  sacrum.  It  is  this  distribution  which  led  to  the  first 
descriptions  of  the  rectum  as  beginning  at  this  point.  Such  an  ar- 
rangement, however,  is  far  from  being  the  most  frequent  one. 

Intersigmoid  Fossa. — "When  the  sigmoid  is  turned  upward  one  sees 


EMBRYOLOGY,  ANATOMY,  AND  PHYSIOLOGY 


41 


at  the  point  where  the  mesosigmoid  crosses  the  iliac  artery  a  circular 
orifice,  10  to  15  millimeters  in  diameter,  which  leads  into  a  funnel-shaped 
cul-de-sac  called  the  intersigmoid  fossa  (Fig.  34). 

This  cul-de-sac  was  first  pointed  out  by  Hensing  and  Eoser.     It  is 
situated  at  the  parietal  insertion  of  the  mesosigmoid  and  a  little  to  the 


Fig.  33. — Line  of  Attachment  of  the  Mesosigmoid. 

left  of  the  median  line.  Its  direction  is  obliquely  upward,  and  from  left 
to  right  in  the  line  of  the  iliac  artery.  Its  depth  varies  from  3  to  6  cen- 
timeters (liV  to  2|  inches),  but  occasionally  it  extends  much  deeper. 
Around  this  orifice  are  situated  the  iliac  artery  below,  and  the  mesen- 
teric or  three  sigmoidal  arteries  above  and  at  the  sides.  It  is  an  impor- 
tant guide,  therefore,  in  pelvic  operations  to  indicate  the  location  of 
these  vessels. 

The  sigmoid  when  empty  ordinarily  falls  down  in  the  recto-vesical 
space  or  Douglas's  cul-de-sac,  and  occupies  the  pelvic  cavity  for  the 


42  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

greater  portion  of  its  extent.  Under  such  circumstances  it  forms  an 
acute  flexure  at  its  juncture  with  the  rectum. 

When  distended  with  gas  or  faecal  material  it  rises  up  in  the  abdom- 
inal cavity  as  high  as  the  umbilicus,  sometimes  to  the  transverse  colon, 
or  even  to  the  diaphragm;  its  distal  end  being  carried  across  into  the 
right  iliac  fossa,  straightens  out  this  angle  between  it  and  the  rectum, 
and  produces  a  comparatively  straight  channel  through  the  two  organs. 

Whenever  by  adhesive  bands,  tumors,  or  any  other  conditions  the  sig- 
moid is  prevented  from  rising  up  in  the  abdominal  cavity,  and  thus 
straightening  out  this  flexure,  a  mechanical  difficulty  in  the  passage  of 
fgecal  material  will  be  presented ;  as  will  be  seen  later  on  in  the  chapter 
upon  Constipation,  this  condition  of  affairs  is  not  at  all  rare. 

Blood  Supply. — The  sigmoid  flexure  receives  its  blood  supply  from 
the  sigmoid  arteries,  branches  of  the  inferior  mesenteric  artery;  they 
run  circularly  around  the  gut  and  anastomose  with  the  colonic  arteries 
above  and  the  superior  haemorrhoidal  arteries  below  (Fig.  34). 

Its  veins  follow  practically  the  same  course  as  the  arteries,  and  empty 
their  blood  into  the  portal  circulation  through  the  inferior  mesenteric 
vein. 

The  arteries  enter  the  mesocolon  at  the  sides  of  the  intersigmoid 
fossa,  and  any  injury  at  this  point  during  operative  procedures  or 
through  prolonged  pressure  from  uterine  tumors  may  be  followed  by 
gangrene  of  the  sigmoid. 

The  Nerves  of  the  Sigmoid. — The  nerves  of  the  sigmoid  are  of  the 
sympathetic  variety,  with  the  exception  of  a  few  fibers  of  the  sensory 
type,  which  are  derived  from  the  lumbar  and  sacral  plexuses  and  dis- 
tributed upon  the  posterior  wall  of  the  gut. 

Relations  of  the  Sigmoid. — Owing  to  the  great  mobility  of  the  sig- 
moid flexure  its  relations  are  very  various.  In  its  upper  or  iliac  portion 
it  is  in  relation  anteriorly  with  the  abdominal  wall,  or  separated  from 
the  same  by  loops  of  small  intestine.  Posteriorly  it  lies  upon  the  iliac 
muscle  and  fascia,  then  upon  the  psoas  muscle  and  left  iliac  vessels, 
then  upon  the  last  lumbar  vertebra,  and  finally  upon  the  right  psoas 
muscle  and  the  anterior  surface  of  the  sacrum.  In  its  course  across  the 
pelvis  it  is  in  relation  anteriorly  with  loops  of  small  intestine,  with  the 
bladder  in  men,  and  with  the  uterus,  ovaries,  and  fimbriated  extremities 
of  the  tubes  in  women.  Adhesions  between  the  latter  organs  and  the 
sigmoid  are  by  no  means  uncommon,  and  account  for  a  great  deal  of  the 
pain  which  women  suffer  from  constipation  and  intestinal  accumulation 
of  gases. 

When  empty  the  sigmoid  lies  almost  entirely  in  the  pelvic  cavity, 
and  is  therefore  called  the  pelvic  colon.  Under  such  circumstances 
it  is  in  relation  anteriorly  and  below  with  the  bladder  in  men,  and 


EMBRYOLOGY,  ANATOMY,  AND  PHYSIOLOGY 


43 


with  the  uterus  in  women.  Posteriorly  it  is  in  relation  with  the  rectum 
and  anterior  surface  of  the  sacrum  in  both  sexes.  Above  it  is  in  relation 
with  the  loops  of  the  small  intestine  which  rest  upon  it. 

When  the  organ  is  much  distended  by  gas  or  faecal  matter  it  rises 
into  the  abdominal  cavity,  and  is  there  practically  surrounded  by  loops 


Fig.  34. — Inteesigmoid  Fossa. 
Showing  left  sigmoidal  artery. 


of  small  intestine  and  the  abdominal  wall  (Engle,  Medicinische  Wochen- 
schrift,  Vienna,  1857,  p.  647;  Jacoby,  American  Journal  of  Medical  Sci- 
ences, 1874;  and  Bouchard,  These,  Paris,  1863). 

Physiology. — The  anus,  rectum,  and  sigmoid,  while  forming  a  por- 
tion of  the  alimentary  tract,  take  no  part  in  the  processes  of  digestion. 
The  sigmoid  and  rectum  are  storehouses  for  the  fsecal  material  after  the 
process  of  digestion  is  complete.     They  are  provided  with  a  system  of 


44  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

glands  or  tubules  which  absorb  from  the  mass  whatever  fluid  or  nour- 
ishing substances  are  left  in  it. 

The  functions  of  the  anus  consist  in  furnishing  an  exit  for  the  fsecal 
material  and  in  controlling  its  discharge  except  at  opportune  moments. 
In  normal  conditions  this  exit  is  wide  enough  to  admit  of  the  passage 
of  well-formed  masses,  and  capable  of  closing  sufficiently  to  retain  abso- 
lutely fluid  materials.  It  is  governed  by  both  voluntary  and  involuntary 
muscles.  Normally  the  aperture  is  closed,  but  this  closure  may  be  ren- 
dered much  more  firm  and  resisting  by  voluntary  action  when  exigencies 
require  it.  The  organ  relaxes  and  opens  through  the  inhibition  of  sphinc- 
teric  contraction  ordinarily  governed  by  will-power.  It  seems  to  be  con- 
trolled by  two  centers:  one  in  the  spinal  cord  and  the  other  in  the  brain. 

Physical  and  anatomical  experiments  and  a  study  of  lesions  of  the 
cord  show  that  the  reflex  center  of  the  anus  and  rectum  is  located 
in  the  cord  nearly  opposite  the  base  of  the  first  lumbar  vertebra  in  the 
very  tip  of  the  cord  or  conus  medullaris. 

The  inhibitory  center  is  situated  in  the  brain.  Injury  to  the  chorda 
and  more  particularly  to  the  conus  is  therefore  followed  by  incontinence, 
while  injury  or  disease  above  this  region  results  in  constipation. 
"  Faeces  or  air  in  the  rectum  excite  the  lumbar  center  and  cause  two 
effects — contraction  in  the  wall  and  relaxation  of  the  sphincter.  This 
process  can  be  controlled  by  the  will  to  a  considerable  extent,  although 
we  are  still  ignorant  of  the  precise  mode  in  which  the  voluntary  influ- 
ence is  exerted.  But  if  the  volitional  path  in  the  cord  is  interrupted 
above  the  lumbar  centers,  the  will  can  no  longer  control  the  reflex  pro- 
cesses; as  soon  as  the  faeces  irritate  the  rectum  they  will  be  expelled  by 
the  reflex  mechanism.  If  the  damage  to  the  cord  involves  the  sensory 
tract,  the  patient  is  unconscious  of  the  action  of  the  bladder  or  bowel. 
If  the  sensory  tract  is  unaffected,  the  patient  is  aware  of  the  process, 
but  can  not  control  it.  It  is  often  said  that  there  is  permanent  relaxa- 
tion of  the  sphincters,  but  this  is  true  only  when  the  lumbar  centers  are 
inactive  or  destroyed.  In  this  condition  evacuation  occurs  as  soon  as  the 
urine  or  fseces  enter  the  bladder  or  rectum.  The  urine  escapes  continu- 
ously instead  of  being  expelled  at  intervals.  The  condition  is  less 
obvious  in  the  case  of  the  rectum,  because  there  is  no  such  continuous 
passage  of  faeces  into  the  rectum  as  there  is  of  urine  into  the  bladder. 
We  may,  however,  distinguish  between  the  two  states  of  the  rectum  by 
the  introduction  of  the  finger.  If  the  lumbar  center  is  inactive,  there 
is  a  momentary  contraction  due  to  local  stimulation  of  the  sphincter, 
and  then  permanent  relaxation.  If,  however,  the  reflex  center  and 
motor  nerves  from  it  are  intact,  the  introduction  of  the  finger  is  fol- 
lowed first  by  relaxation  and  then  by  gentle,  firm,  tonic  contraction  " 
(Gowers,  Diseases  of  the  Nervous  System,  vol.  i,  p.  246). 


EMBRYOLOGY,  ANATOMY,  AND  PHYSIOLOGY  45 

The  functions  of  the  rectum  and  sigmoid  are  practically  the  same. 
They  are  both  receptacles  or  reservoirs  for  the  faecal  material  after  it 
has  passed  through  the  intestinal  canal.  The  material  is  softer  and  more 
fluid  in  the  sigmoid  than  in  the  rectum ;  it  is  also  more  constantly  pres- 
ent in  the  former.  It  is  not  true,  however,  as  is  frequently  stated,  that 
the  rectum  is  always  empty  except  just  before  the  period  of  defecation. 
It  nearly  always  contains  more  or  less  faecal  matter.  The  writer  has 
made  many  examinations  with  regard  to  this  fact,  and,  except  in  cases  of 
impaction,  he  has  never  found  a  case  in  which  the  rectum  was  empty 
and  the  sigmoid  well  filled  with  faecal  material.  They  both  act  as  reser- 
voirs, and  a  certain  amount  of  faecal  material  is  always  present  in  them. 

The  theory  and  processes  of  defecation,  together  with  O'Beirne's 
doctrine  of  retro-peristaltic  action  by  which  the  faecal  mass  is  lifted  back 
into  the  sigmoid  after  it  has  once  entered  the  rectum,  will  all  be  dis- 
cussed in  the  chapter  upon  constipation,  as  they  bear  directly  upon  this 
subject.  It  is  sufficient  to  state  here  that  after  a  great  many  ocular  ex- 
aminations of  the  rectum  and  sigmoid,  the  author  has  never  seen  a  case 
in  which  the  faecal  matter,  having  once  entered  the  rectum,  has  been 
lifted  back  into  the  sigmoid  flexure. 

Owing  to  their  glandular  apparatus,  both  the  rectum  and  sigmoid 
act  as  absorptive  and  secretive  organs.  The  longer  the  faecal  mass  re- 
mains in  them,  the  drier  will  it  become  through  the  absorption  of  its 
fluid  materials  by  the  Lieberkiihn  follicles.  This  absorptive  action  of 
the  rectum  is  made  use  of  by  physicians  for  the  stimulation  or  nour- 
ishment of  patients  when  feeding  by  the  stomach  is  impracticable.  Cer- 
tain medicinal  substances  seem  to  enter  the  circulation  much  more  rap- 
idly through  this  route  than  through  the  stomach.  As  examples,  we  may 
mention  cocaine,  belladonna,  hyoscyamus,  and  opium.  Whether  absorp-' 
tion  takes  place  through  the  blood-vessels,  or  through  the  epithelial  cells, 
or  through  the  intercellular  substance  between  the  individual  cells,  is 
not  clear.  Cripps  (op.  cit.,  p.  16)  doubts  the  existence  of  the  intercel- 
lular substance,  and  says  that  "  it  is  highly  probable  absorption  takes 
place  through  the  epithelial  cells  themselves.  Possibly  the  nuclei  of 
the  columnar  epithelium  may  be  the  means  of  taking  nourishment  into 
the  body  by  escaping  into  the  retiform  tissue  between  the  glands,  and 
thus  becoming  lymphoid  cells.  According  to  this  view,  the  columnar 
epithelial  cells  lining  the  rectal  follicles  have  a  far  higher  function  than 
that  generally  assigned  to  them  by  physiologists,  and  instead  of  being 
employed  in  a  simple  secretion  of  mucus,  they  are  in  reality  the  parents 
of  leucocytes  of  the  body."  This  theory  is  interesting,  and  its  author 
has  produced  some  microscopic  evidence  in  its  favor,  but  the  necessarily 
slow  processes  of  such  absorption  are  not  in  keeping  with  the  rapid  entry 
into  the  circulation  of  certain  substances  when  introduced  into  the  rec- 


46  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

turn.  Considering  the  large  capillary  and  vascular  supply  of  the  rectum, 
it  seems  more  probable  that  absorption  takes  place  through  these,  and 
that  the  absorbed  fluid  enters  directly  into  the  circulation.  The  secre- 
tory functions  of  the  rectum  and  sigmoid  consist  in  secreting  mucus  in 
greater  or  less  quantity,  which  lubricates  the  faecal  mass  when  dry,  and 
thus  facilitates  its  passage  with  the  least  possible  friction.  The  amount 
of  mucus  secreted  depends  upon  the  dryness  and  irritating  qualities  of 
the  fa?cal  material.  In  normal  conditions  it  is  barely  perceptible,  but 
in  cases  of  chronic  constipation  or  acute  catarrhal  inflammation,  it  be- 
comes greatly  exaggerated,  and  sometimes  exhausting  to  the  patient, 
even  where  it  is  not  accompanied  by  discharge  of  blood  or  pus. 


CHAPTER    II 

MALFORJilATIOyS   OF   THE  AXUS  AND  RECTUM 

While  the  proportion  of  malformations  of  the  anus  and  rectum  m 
the  total  number  of  children  born  is  very  small,  the  actual  number  is 
far  from  inconsiderable.  Moreau  stated  to  the  Paris  Academy  of  ]\Iedi- 
cine  that  he  had  observed  during  a  practice  of  forty  years  in  the  Mater- 
nit}^  Hospital  only  four  cases  of  imperforate  anus.  Couty,  of  Havre,  in 
an  experience  of  3,500  confinements  saw  3  cases.  Collins,  in  the  Mater- 
nity Hospital  of  Dublin,  saw  only  1  case  in  16,000  children,  while  Zohre, 
of  the  A^ienna  Maternity  Hospital,  reported  only  2  imperforations  in 
50,000  children  born  in  that  institution.  In  the  Paris  Maternity  Hospital 
from  1871  to  1885  there  were  5  cases  of  ano-rectal  malformations  in 
20,600  births,  and  in  the  Cochin  lying-in  hospital  during  the  same  period 
there  was  only  1  case  in  10,572  births.  These  facts  agree  in  the  main 
with  the  estimate  of  Starr,  who  stated  that  these  malformations  occurred 
about  once  in  10,000  births. 

Authors  differ  as  to  their  relative  frequency  in  the  two  sexes.  Thus, 
while  Sedillot  states  that  girls  always  furnish  the  greatest  number  of 
ano-rectal  anomalies,  Curling  found  in  100  such  cases  58  bo^'^s  and  42 
girls;  Bouisson  in  the  same  number  of  children  found  53  girls  and  47 
boys.  In  our  own  collection  of  140  cases  so  far  as  the  sex  was  known 
there  were  52  boys  and  70  girls.  If  the  cases  of  atresia  ani  vaginalis 
are  included,  the  preponderance  will  be  in  favor  of  the  female  sex,  but 
omitting  these  cases,  there  is  no  appreciable  difference  in  the  frequency 
with  which  malformations  occur  in  the  two  sexes.  These  statistics  all 
refer  to  gross  malformations,  and  are  not  entirely  accurate,  inasmuch  as 
many  of  these  abnormalities  are  of  a  partial  nature  and  present  no  phys- 
ical symptoms  calling  attention  to  them  in  early  life.  As  a  consequence 
the  victims  often  go  to  old  age  without  knowing  that  any  deformity 
exists. 

The  neglect  of  systematic  examination  of  the  rectum  in  new-born 
children  by  accoucheurs  and  midwives  allows  many  of  these  minor  mal- 
formations to  go  unobserved.  Thus  one  sees  quite  frequently  instances 
of  congenital  stricture,  valvular  occlusion,  and  rectal  malformations  in 

47 


48  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

persons  who  have  reached  the  age  of  puberty,  supposing  they  were  ana- 
tomically perfect.  Morgagni  records  a  case  of  this  kind  in  which  a 
woman  who  lived  to  be  one  hundred  years  of  age,  was  married,  bore  chil- 
dren, and  performed  all  the  duties  of  life  without  knowing  she  had  any 
malformation  until  shortly  before  her  death. 

The  importance  of  such  examination  and  the  early  recognition  of 
malformations  can  not  be  overestimated,  for  it  is  only  in  the  earliest 
stages  that  we  can  hope  to  remedy  the  cases  of  complete  occlusion,  and 
it  is  at  this  stage  also  that  we  may  do  most  to  prevent  the  minor  malfor- 
mations proving  serious  in  later  life. 

Welch,  of  Baltimore,  has  shown  that  the  meconium  at  the  time  of 
birth  and  for  some  hours  thereafter  is  a  sterile  fluid,  but  that  after 
the  digestive  processes  have  taken  place  in  the  intestinal  canal  it  be- 
comes infectious  and  is  no  longer  free  from  danger  to  surgical  wounds. 
This  fact  would  indicate  the  advantages  of  early  operation  from  an  asep- 
tic point  of  view,  for  it  is  the  rule  in  such  operations  that  the  meconium 
escapes  into  the  wound  and  thus  exposes  the  latter  to  whatever  infec- 
tious germs  it  may  contain.  The  large  majority  of  deaths  from  opera- 
tions of  this  kind  are  due  to  peritonitis  or  sepsis  which  follow  the  escape 
of  the  intestinal  contents  into  the  peritoneal  cavity  or  wound.  The 
earlier,  therefore,  that  remedial  measures  are  undertaken,  the  less  dan- 
ger will  there  be  of  septic  infection. 

In  the  section  on  embryology  it  was  shown  that  the  rectum  and 
anus  are  developed  from  two  entirely  different  layers  of  the  blasto- 
derm, that  the  blood  supply  of  these  two  organs  come  from  different 
sources  and  return  by  different  routes  to  the  general  circulation.  Arrest 
in  the  development  of  one,  therefore,  is  not  necessarily  associated  with 
that  in  the  other;  in  the  majority  of  cases  where  there  is  malformation 
or  displacement  of  the  rectum,  the  anus  is  ordinarily  normal,  and  vice 
versa.  On  the  other  hand,  malformation  of  either  one  of  these  organs  is 
very  likely  to  be  associated  with  malformation  in  other  parts  of  the  body 
derived  from  the  same  layer  of  the  blastoderm.  Thus,  children  with  mal- 
formations of  the  rectum  are  very  likely  to  suffer  with  cleft  palate,  nasal 
and  pharyngeal  obstructions,  or  other  abnormalities  of  the  alimentary 
tract.  Those  with  malformations  of  the  anus  are  likely  to  be  associated 
with  malformations  of  the  uro-genital  organs,  such  as  hypospadias,  ex- 
strophy of  the  bladder,  atresia  ani  vaginalis,  etc. :  Other  malformations, 
such  as  deformities  of  the  pelvis,  absence  or  twisting  of  the  coccyx,  close 
apposition  of  the  tuber  ischii,  and  absence  or  imperfect  formation  of  the 
perinaeum,  may  be  associated  with  malformations  of  the  rectum  and  anus. 
It  is  not  within  the  scope  of  this  book,  however,  to  consider  monstrosities, 
so  the  text  will  be  restricted  to  those  malformations  affecting  the  rectum 
and  anus  only. 


MALFORMATIONS  OP  THE  ANUS  AND  RECTUM  49 

The  classical  division  of  these  malformations  was  first  laid  down 
by  Pappendorf  in  1781,  and  has  been  closely  followed  by  most  writers 
since  his  day.  In  this  classification  the  rectum  and  anus  are  considered 
as  one  and  the  same  organ,  and  no  distinction  is  made  between  malfor- 
mations resulting  from  arrest  of  development  in  the  parts  originating  in 
the  epiblast  and  those  originating  in  the  hypoblast  and  mesoblast.  As 
the  writer  has  always  observed  this  distinction,  Pappendorf's  division  is 
modified  as  follows : 

Malformations  of  the  Anus 

a.  Entire  absence  of  the  anus. 

b.  Abnormal  narroiving  of  the  anus. 
e.  Partial  occlusion  of  the  anus. 

d.  Absolute  occlusion  of  the  anus. 

e.  Anal  opening  at  some  abnormal  point  in  the  perineal,  scrotal, 
or  sacral  region. 

Malformations  of  the  Rectum 

a.  Rectum  entirely  absent. 

b.  Rectum  arrested  in  its  descent  at  a  point  more  or  less  removed 
from  the  anus,  the  anus  being  normal. 

c.  Rectum  opening  into  some  other  viscus,  with  anus  present  in  its 
normal  position  or  absent. 

d.  Rectum  and  anus  normal,  unth  the  exception  that  the  ureter, 
bladder,  vagina,  urethra,  or  uterus  opens  into  the  rectum. 

With  this  division  we  are  able  to  clearly  follow  out  the  malforma- 
tions due  to  the  arrest  of  development  in  the  different  layers  of  the 
blastoderm. 

MALFORMATIONS    OF    THE    ANUS 

a.  Entire  Absence  of  the  Anus. 

Cases  in  which  the  anus  is  entirely  absent  are  comparatively  rare. 

The  nurse  or  medical  attendant  when  examining  the  child  for  sex 
will  immediately  recognize  the  entire  absence  of  the  anus,  whereas  if 
it  is  only  partially  formed  the  deformity  is  generally  overlooked.  In 
these  cases  there  may  be  a  depression  in  the  skin  at  the  point  where  the 
anus  should  be,  but  sometimes  there  is  a  small  corrugated  button  of 
skin  or  protrusion  at  this  point.  At  other  times  there  is  simply  a  slight 
discoloration,  with  more  or  less  rugse  of  the  skin  tissue  centering  around 
the  normal  point.  Again,  the  skin  or  central  rhaphe  of  the  perinfeum 
may  extend  in  an  unbroken  line  from  the  scrotum  to  the  coccyx  (Fig.  35). 
In  such  cases  the  rectum  may  reach  down  almost  to  the  skin,  it  may  open 
into  some  other  viscus,  or  it  may  be  arrested  in  its  descent  at  a  greater  or 
4 


50 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


less  distance  from  the  point  of  the  normal  anus.  The  existence  or  ab- 
sence of  a  depression  at  the  point  where  the  normal  anus  should  be  is  no 
indication  whatever  of  the  distance  at  which  the  rectum  will  be  found. 
In  some  cases  where  there  is  a  marked  depression,  or  even  a  well-formed 

anus,  the  rectum  will 
be  found  high  up, 
whereas  in  other  cases 
in  which  there  is  not 
the  slightest  indication 
of  an  anus  the  rectum 
will  be  found  close  to 
the  surface  of  the  skin. 
This  fact  is  of  impor- 
tance from  a  practical 
point  of  view,  showing 
that  the  absence  or 
very  slight  develop- 
ment of  the  anus 
would  be  no  indication 
for  doing  an  abdom- 
inal operation  for  ini- 
perforation  until  a 
careful  search  through 
the  perineum  had 
been  made. 

Associated  with  this 
form  of  malformation 
we  are  likely  to  have 
other  deformities  in 
the  external  genital  organs,  such  as  atrophy  of  the  vagina,  hypo- 
spadias, exstrophy  of  the  bladder,  and  deformities  of  the  pelvis.  The 
tuberi  ischii  are  likely  to  be  unusually  close  together,  and  the  pelvis 
itself  ma}'  be  so  narrow  and  generally  smaller  than  normal  that 
the  deformities  will  be  observable  from  a  simple  inspection  of  the 
parts.  The  genital  organs  also  may  be  set  farther  back  toward  the  coc- 
cyx, and  the  space  between  the  bladder  and  the  sacrum  may  be  so  narrow 
that  it  would  be  almost  impossible  to  insert  the  finger  between  them. 
These  malformations  it  will  be  seen  arise  in  tissues  all  having  their 
origin,  as  the  anus,  in  the  epiblast,  and  may  be  independent  of  any  de- 
formities or  arrests  of  development  in  the  tissues  arising  from  the  other 
layers  of  the  blastoderm. 

Diagnosis. — Where  the  anus  is  absent  there  is  no  difficulty  in  recog- 
nizing the  fact  by  sight.    Where  such  observation  is  not  made  at  the  time 


Fig.  35. — Complete  Absence  of  the  Anv- 


MALFORMATIONS  OF  THE  ANUS  AXD  RECTUM  51 

of  birth  it  will  soon  be  noticed  that  there  is  no  passage  of  meconium  or 
fscal  matter;  that  the  child  is  restless,  and  soon  begins  to  strain;  the 
abdomen  becomes  tense  and  swollen,  and  after  a  few  days  the  child  ejects 
its  food,  digested  or  undigested,  according  to  the  state  of  the  stomach. 
With  the  first  appearance  of  such  symptoms,  ocular  and  digital  examina- 
tions are  called  for,  and  when  these  are  made  there  is  no  difficulty  to 
diagnose  the  malformation.  As  this  is  one  of  the  types  of  imperforate 
anus,  the  consideration  of  treatment  will  be  postponed  until  all  have 
been  described. 

h.  Abnormal  Narrowing  of  the  Anus. 

In  these  cases  the  anus  is  present,  and  may  appear  perfectly  normal 
to  the  superficial  observer,  but  upon  examination  it  will  be  shown  that 
it  is  unusually  narrow  at  some  portion.  This  narrowing  may  take  place 
at  any  point  from  the  margin  to  its  junction  with  the  rectum,  or  it  may 
extend  throughout  the  whole  length  of  the  anus.  As  the  length  of  the 
normal  anus  is  from  1  to  2^  centimeters  (|  to  1  inch),  the  narrowing 
which  can  be  properly  attributed  to  it  will  be  limited  to  this  extent. 

The  narrowing  may  be  annular  and  very  short,  being  formed  by 
bands  or  membranes  extending  from  one  side  of  the  anus  to  the  other, 
or  it  may  extend  from  the  margin  to  the  upper  limits  of  the  anus, 
consisting  in  a  general  incapacity  of  the  entire  anal  canal.  This  condi- 
tion differs  from  the  narrowing  of  later  life  produced  by  pathological 
causes  in  that  there  is  no  hypertrophy  of  connective  tissue,  no  cicatricial 
tissue,  and  no  hardening  of  the  parts;  the  anus  is  soft  and  flexible,  and 
its  walls  continue  so  upward  to  the  rectum.  The  conditions  attributable 
to  inflammation  may  develojD  later  on  in  life,  owing  to  the  passage  of 
faecal  matter  through  this  abnormally  narrow  channel,  and  the  conse- 
quent irritation  therefrom,  but  in  those  cases  which  have  been  observed 
at  the  time  of  birth  there  has  not  yet  been  reported  any  evidence  of 
pathological  processes  having  taken  place. 

The  question  of  the  size  of  a  normal  anus  at  the  time  of  birth  is 
rather  difficult  to  decide;  it  depends  upon  the  size  of  the  child,  but  in 
general  one  may  say  that  the  anal  canal  at  birth  ought  to  admit  with  com- 
parative ease  the  little  finger  of  a  man's  hand,  or  the  index  finger  of  a 
woman's.  If  the  sphincters  are  normally  developed  they  will  be  found 
to  grasp  the  finger  gently,  and  yet  easily  enough  to  admit  its  passage 
well  into  the  rectum;  where  there  is  abnormal  narrowing  this  sphinc- 
teric  action  is  generally  deficient,  and  one  finds  it  difficult  or  impossible 
to  introduce  the  finger  through  the  contracted  canal.  These  cases  are 
the  ones  in  which  children  are  reported  to  have  been  constipated  all  their 
lives,  and  who  frequently  develop  strictures  or  fissures  in  early  life. 

Pailhes,  in  a  thesis  before  the  medital  faculty  of  Paris,  discusses  this 
subject  at  length  from  the  point  of  view  of  congenital  strictures.     He 


52  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

shows  that  many  of  these  cases  reach  adult  and  even  old  age  without 
discovering  the  true  nature  of  their  condition,  and  yet  their  histories 
and  lifelong  experiences  would  go  to  prove  that  the  narrowing  had  ex- 
isted at  the  time  of  birth.  We  must  differ  with  Trelat,  Reynier,  and 
Pailhes  in  calling  this  condition  stricture  at  the  time  of  birth,  because 
that  term  designates  a  pathological  narrowing  of  a  canal  which  has  been 
of  normal  proportions,  and  they  all  disclaim  any  such  process  in  its 
production.  The  pathological  condition  in  these  cases  comes  on  after 
birth  through  obstruction  and  consequent  irritation  from  the  faecal  pas- 
sages. It  is  true  when  these  cases  are  treated  in  adult  and  later  life 
that  the  condition  is  then  one  of  stricture  with  all  its  pathological  ac- 
companiments, and  may  be  classed  (as  Pailhes  has  done)  under  the  head- 
ing of  congenital  stricture,  referring,  of  course,  to  its  origin  and  not 
to  its  pathology;  but  the  congenital  feature  consists  in  an  abnormally 
small  anal  canal  incapable  of  being  dilated  by  the  faecal  mass. 

Diagnosis. — The  diagnosis  of  this  condition  is  not  so  easy  as  that  of 
total  absence  of  the  anus.  There  is  generally  more  or  less  room  for  the 
passage  of  the  meconium,  and  as  gas  escapes  through  very  small  pas- 
sages, the  child  in  early  life  is  not  much  disturbed  by  its  accumulation. 
As  long  as  the  fa^-al  passages  are  semifluid,  as  they  should  be  in  infant 
life,  these  abnormal  narrowings  of  the  anus  will  produce  no  subjective 
symptoms;  but  as  soon  as  the  faecal  material  begins  to  be  solid,  obstruc- 
tion and  irritation  will  take  place,  and  the  patient  will  have  to  strain 
and  suffer  pain  whenever  a  movement  of  the  bowels  occurs.  Such  chil- 
dren soon  learn  to  dread  the  hour  for  being  sent  to  the  commode,  and 
the  result  is  a  marked  constipation  with  all  its  evil  effects.  The  only 
absolute  diagnosis  of  these  malformations  is  that  made  by  the  eye  and 
finger. 

Serremone  has  called  attention  to  congenital  narrowing  as  a  frequent 
cause  of  fissures,  both  in  children  and  in  adults.  When  these  fissures 
are  found  in  infancy,  however,  they  must  be  clearly  distinguished  from 
those  due  to  the  dry,  brittle  mucous  membrane  found  in  hereditary 
syphilis.  Digital  examination  in  these  cases  will  elicit  a  narrowing  at 
one  point  or  throughout  the  entire  length  of  the  anus.  AVhen  the  canal  is 
large  enough  to  admit  the  tip  of  the  finger,  the  extent  of  the  malforma- 
tion and  the  density  of  the  surrounding  tissues  can  be  easily  told.  When 
it  is  too  small  for  such  examination,  the  uterine  probe  or  some  such 
instrument  can  be  passed  through,  and,  being  bent  upon  itself,  one 
may  be  able  to  determine  the  nature  and  extent  of  the  narrowing. 
The  older  the  patient  is,  the  more  dense  and  inelastic  will  be  the 
constrictures;  and  tlie  more  unyielding  they  are,  the  more  distress  will 
they  occasion. 

The  child  may  pass  through  infancy  and  childhood  with  no  other 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM 


53 


symptoms  than  those  of  constipation.  This,  however,  may  alternate 
with  a  pseudo-diarrhoja — that  is,  the  child  ma}'  have  impaction,  and  yet 
at  the  same  time  suffer  from  the  frequent  passage  of  fluid  fseces  around 
the  fffical  mass.  The  author  saw  an  interesting  case  of  this  kind  some 
years  since  in  a  boy  four  years  of  age,  who  was  brought  to  the  clinic  on 
account  of  the  diarrhoea.  He  was  having  twenty  to  thirty  passages 
daily,  was  emaciated,  pale,  and  septic  in  appearance,  his  abdomen  was 
greatly  distended,  and  his  physiognomy  suggested  tubercular  enteritis. 
Examination  under  chloroform  revealed  a  narrow  tubular  anus  not 
large  enough  to  admit  the  little  finger,  and  incapable  of  being  dilated 
without  tearing.  It  was  therefore  incised  posteriorly.  Within  the  fol- 
lowing hour  he  passed  more  than  six  pounds  of  hard,  lumpy  f^ces.  An 
examination  of  the  child's  rectum  at  birth  would  have  shown  this  de- 
formit}^  and  persistent  dilatation  at  that  time  would  have  prevented 
the  suffering  and  necessity  of  operation. 

Those  cases  in  which  the  narrowing  is  not  observed  until  in  adult 
life  can  only  be  recognized  as  congenital  from  the  subjective  history. 
Kelsey  (Diseases  of  the  Eectum  and  Anus,  p.  74)  has  related  a  case  in 
which  the  condition  was  discovered  at  the  age  of  thirty-eight.  Trelat 
saw  one  at  fifty-two,  and  the  author 
has  seen  one  at  twenty-seven.  N^one 
of  these  patients  had  any  idea  they 
were  malformed.  In  general  terms 
one  may  say  an  anus  that  will  not 
admit  a  ISTo.  5  Wales  bougie  in  in- 
fants, or  a  ISTo.  7  in  adults,  may  be 
called  abnormally  narrow. 

c.  Partial  Membranous  Occlu- 
sion of  the  Anus. 

This  variety  of  malformation  of 
the  anus  is  not  rare.  It  consists 
in  a  partial  occlusion  at  some  level 
of  the  anal  canal  by  a  membrane 
or  fold  of  tissue.  If  the  fold  is 
situated  at  the  margin  or  outside 
of  the  anal  canal  it  is  composed  of 
skin.  Sometimes  it  occurs  in  the 
shape  of  a  central  rhaphe  extend- 
ing from  the  scrotum  to  the  coccyx, 

with  a  small  opening  on  one  side  or  both,  at  the  point  where  the  anus 
should  be,  thus  allowing  the  passage  of  fluid  faeces  or  meconium 
(Fig.  36). 

When  the  occlusion  is  higher  up,  the  membrane  is  composed  of  muco- 


FlG. 


-MEMr,i;AX"r=  < 'i'  lusiojj"  of  the- 
Anus. 


54 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


cutaneous  tissue,  and  has  a  crescentic  or  circular  shape  with  a  small 
opening  either  in  the  middle  or  upon  one  side.  These  openings  may  be 
of  considerable  size,  or  barely  large  enough  to  admit  a  probe.  The 
smaller  the  opening,  the  more  likely  it  is  to  produce  constitutional  and 
subjective  symptoms  early  in  life.  When  the  membrane  is  situated  as 
high  as  1|  to  2  centimeters  (|  to  f  of  an  inch)  from  the  margin  of  the 
anus,  it  will  be  due  probably  to  imperfect  absorption  of  the  ano-rectal 
membrane.  Such  cases,  however,  must  be  distinguished  from  those  in 
which  there  is  an  abnormal  fold  lower  down.  These  cases  have  been 
described  as  congenital  strictures,  but  should  be  classified  under  the  head 
of  congenital  malformations.  As  in  the  previous  class,  they  have  neither 
the  pathological  nor  physical  characteristics  of  stricture.  They  are  gen- 
erally observed  earlier  in  life  than  the  preceding  class,  and  are  much 
more  easily  dealt  with,  in  that  they  do  not  involve  the  deeper  layers  of 
the  anal  wall.  When  attention  has  been  once  called  to  them  the  diag- 
nosis is  easy,  because 
all  of  the  malformation 
is  within  reach  of  the 
finger  or  the  probe,  as 
well  as  within  ocular 
observation.  They  are 
frequently  seen  in  adult 
life,  and  produce  so 
little  disturbance  that 
they  are  of  no  surgical 
importance  (Fig.  37). 

d.  Complete  Obstruc- 
tion of  the  Anus  by 
a  Membranous  Dia- 
phragm. 

The  distinction  be- 
tween this  and  the  last 
variety  of  malformation 
of  the  anus  is  simply 
one  of  degree.  The 
former  represented  a 
partial  occlusion  not  immediately  dangerous  to  life,  while  this  represents 
a  complete  occlusion,  which  must  be  overcome  in  order  that  the  child  may 
live.  Such  cases  are  extremely  rare,  and  are  among  the  easiest  to  rem- 
edy. In  these  the  anus  is  simply  closed  by  a  thin  membranous  diaphragm 
resembling  very  much  the  hymen,  which  is  composed  of  fibrous  or  muco- 
cutaneous tissue,  very  thin  and  flexible,  that  extends  in  crescentic  layers 
from  one  wall  of  the  anus  to  the  other.    If  the  rectum  is  properly  devel- 


FiG.  37. — Pabtial  MEMBRANors-  Occlusion  of  the  Anus. 
Observed  in  a  man  Ibi'ty-two  years  of  age. 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM  55 

oped  in  these  cases  one  can  easily  see  or  feel  the  bulging  of  the  meconium 
against  this  thin  diaphanous  membrane. 

It  has  been  assumed  that  this  form  of  malformation  is  simply  an 
arrest  in  the  absorption  of  the  membrane  dividing  the  proctodeum  and 
the  enteron.  Its  location  in  some  cases  is  too  low  down  to  justify  any 
such  general  conclusion.  The  measurement  laid  down  by  Trelat^  and 
again  by  Bodenhamer,  gives  the  length  of  the  anus  as  1^  centimeter  (f 
of  an  inch)  at  the  time  of  birth.  Now^  if  this  diaphragm  were  the 
unabsorbed  membrane  between  these  two  portions  of  the  intestine,  it 
would  be  located  at  the  level  at  which  the  partition  is  found.  Writers 
who  have  described  these  cases  speak  of  them  as  being  found  at  ^  a 
centimeter,  f  of  a  centimeter,  and  at  1  centimeter  from  the  anal  margin. 
The  author  has  seen  three  such  cases.  In  one  the  membrane  was  situ- 
ated just  ^  a  centimeter  (-j^g-  of  an  inch)  from  the  margin  of  the  anus; 
in  another  it  was  situated  a  little  less  than  1  centimeter  (f  of  an  inch)  ; 
and  in  the  third  at  almost  exactly  1  centimeter.  They  were  all  covered 
below  with  a  muco-cutaneous  membrane.  The  membrane  in  one  case  was 
so  thin  that  it  was  punctured  with  the  flat  end  of  an  ordinary  probe, 
and  then  divulsed  by  the  fingers.  Four  3'ears  afterward  this  child  was 
seen,  and  there  was  no  evidence  of  the  remains  of  the  membrane,  but  the 
sagittal  line  of  the  pecten  was  clearly  marked  and  well  above  the  point 
at  which  the  membrane  was  attached,  judging  by  measurement.  In  the 
other  two  cases  later  observations  were  not  obtainable.  One  should  not 
infer  from  this  that  occlusions  from  arrest  in  absorption  of  the  sseptum 
between  the  proctodseum  and  enteron  do  not  occur,  for  they  do ;  but  they 
are  not  the  only  membranous  occlusions  of  the  anus.  Later  on  we  will 
see  that  in  some  cases  the  anus  is  occluded  by  one  and  the  rectum  by 
another  separate  and  distinct  membrane. 

Diagnosis. — The  diagnosis  of  these  cases  is  based  upon  the  absence 
of  discharges  of  meconium,  inability  to  introduce  the  finger  into  the 
rectum,  the  obstruction  being  low  down,  and  the  thin  fiuctuating  feel  of 
the  occluding  membrane. 

e.  Anal  Opening  at  some  Abnormal  Point  in  the  Perinseum  or  Sacral 
Eegion. 

This  variety  of  malformation  is  described  ordinarily  as  a  malforma- 
tion of  the  rectum  itself,  and  in  some  instances  it  is  such,  for  we  have 
cases  in  which  the  anus  is  more  or  less  developed  in  its  proper  site,  and 
yet  the  rectum  opens  at  some  other  point  of  the  perineal  or  sacral  region. 
In  the  majority  of  cases,  however,  where  the  rectum  opens  at  one  of 
these  abnormal  positions  there  is  no  other  anus  present,  and  a  careful 
examination  of  the  abnormal  opening  will  show  that  there  is  a  more  or 
less  developed  sphincter  around  the  apertur§.  Where  such  a  sphincter 
exists,  it  seems  quite  natural  to  call  this  opening  the  anus,  especially 


56 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


if  we  can  show  that  the  pavement  epithelium  which  covers  the  skin  and 
Hnes  the  lower  portion  of  the  intestinal  canal  extends  for  any  distance 
upward  in  the  abnormal  opening.  Where  this  pavement  epithelium 
ceases  abruptly  upon  the  edge,  and  is  transformed  into  columnar  epi- 
theliitm,  without  evidence  of  the  gradual  transition  between  the  two 
seen  in  the  normal  anus  and  rectum,  then  we  may  properly  classify  them 
under  malformations  of  the  rectum. 

There  is  no  fixed  position,  nor  even  a  general  one  in  which  such 
openings  may  be  found;  in  fact,  sometimes  there  is  more  than  one  orifice. 
The  openings  may  be  in  the  anterior  or  posterior  part  of  the  perinaeum 

(Fig.  38),  to  one  side 
;T}  or  the  other  of  the 
sacrum,  or  outside  of 
the  gluteal  fold.  In- 
deed, the  rectum  or 
the  small  intestine  has 
been  known  to  open 
on  the  thigh,  the  ab- 
domen, and  the  shoul- 
der. The  anus  is  usu- 
ally developed  in  the 
normal  site  in  the  lat- 
ter cases. 

It  is  not  intended 
to  classify  under  this 
head  those  cases  in 
which  the  rectum 
opens  at  such  remote 
points,  or  into  other 
organs.  We  refer  here 
to  those  in  which  the 
anus  opens  at  an  ab- 
normal position  in  the 
perinaeum  or  sacral  re- 
gion. They  have  been 
described  by  some  as 
fistulous  openings,  but 
they  have  none  of  the 
pathological  characteristics  of  fistula.  There  is  no  pus  associated  with 
them,  there  is  no  cicatricial  contraction  at  the  time  of  birth,  and  there 
is  every  evidence  tliat  the  folding  in  of  the  epiblast  simply  occurred 
at  an  abnormal  position. 

Diagnosis. — The  diagnosis  of  such  cases  consists  simply  in  seeing 


Fig.  38. — Axis  opexixg  at  Tip  of  Coccyx. 


MALPOEMATIONS   OF  THE  AXUS  AND   RECTUM 


57 


them.  It  is  important,  however,  to  determine  whether  there  is  sphinc- 
teric  control  over  the  passages.  If  there  is,  interference  will  not  be 
justified;  but  if  there  is  not,  it  should  be  undertaken  as  soon  as  the 
child's  condition  will  admit  of  it  with  safety. 


MALFORMATIONS    OF    THE    RECTUM 

a.  Entire  Absence  of  the  Rectum. 

This  variety  of  malformation  is  one  which  it  is  impossible  to  diag- 
nose Avithout  exploratory  incision.  The  condition  of  the  external  parts 
in  no  wise  indicates  the  j^robable  absence  of  the  rectum.  In  those  cases 
in  which  the  imperfo- 
rate anus  is  well  formed 
the  rectum  may  be 
close  at  hand,  hanging 
loosely  in  the  pelvic 
cavity,  attached  to 
some  other  portion  of 
the  abdominal  wall,  or 
it  may  be  entirely  ab- 
sent (Fig.  39).  In  cases 
where  there  is  no  ex- 
ternal evidence  of  an 
anus  or  rectum,  the 
latter  may  be  closely 
attached  to  the  perineal 
skin.  No  defects  of 
surface  conformation 
are  sufficient  to  predi- 
cate the  entire  absence 
of  the  rectum.  Boden- 
hamer  and  Verneuil 
have  suggested  the  use 
of  the  stethoscope  ap- 
plied  to    the    perineal 

region      to      determine       ^'^-  S'a-C.mplete  Absence  of  the   Eectum,  the  Colon 

^  ENDING    IN    A    LaEGE     DILATATION    AND    THE     AnLS    BEING 

the    existence    of    gas         noemal. 
in    imperforate     anus. 

The  information  obtained  from  this  is  so  far  from  reliable  that  one 
can  only  call  it  a  negative  process.  The  absence  of  the  rectum  can 
be  determined  only  by  a  search  through  both  the  perineal  and  abdom- 
inal routes. 

The  entire  absence  of  the  large  intestine  forms  one  variety  of  mal- 


58 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


formation  in  the  revised  classification  of  Pappendorf  and  Bodenhamer. 

In  such  cases  the  small  intestine  opens  at  some  abnormal  position,  as, 

for  example,  the  shoulder,  the 
neck,  the  chest,  the  oesophagus, 
the  stomach,  or,  as  in  some  in- 
stances, through  the  umbilicus. 
Such  cases,  however,  are  be3'^ond 
the  domain  of  rectal  surgery  only 
in  so  far  that  if  the  child  should 
reach  the  age  at  which  it  would 
bear  surgical  interference  well, 
an  artificial  anus,  either  in  the 
perinseum  or  at  some  convenient 
position  of  the  abdominal  wall, 
might  be  made  to  take  the  place 
of  these  abnormal  openings. 

h.  The  Rectum  arrested  in  its 
Descent  more  or  less  removed 
from  the  Anus,  the  Anus  being 
Normal. 

In  this  variety  of  malforma- 
tion the  enteron  is  either  arrest- 
ed in  development  and  fails  to 
come  in  apposition  with  the  proc- 

tods-um  (Fig.  40),  or  it  may  pass  downward  in  the  wrong  direction  and 

parallel  with  the  cul-de-sac-  of  the  proctodanmi  (Fig.  41).    The  distance 

at  which  the  rectum  is  arrested 

above  the  anus  is  very  variable. 

Sometimes  it  is  only  a  few  lines 

removed,    while    at    others    it    is 

found   entirely   above   the   pelvic 

cavity.     Again   it  may  be   appar- 
ently in  apposition  with  the  anal 

cul-de-sac,  and  yet,  when  the  mem- 
brane dividing  the  two  is  incised, 

no    meconium    will    appear.      In 

such    cases    there    exist    multiple 

obstructions.      Friedberg,    quoted 

by  Ball,  mentions  a  case  of  this 

kind  in  which  the  walls  of  the 

intestine  were  found  adhering  to 

each    other    in    two    places,    and       ^^^  41.-Case  m  ^hich  the  Rectvm  de- 

Schenck  records  a  similar  case  in  scznded  Posterior  to  the  Anal  Canal. 


Fig.  40. — Case  in  which  the  Rectum 

FAILED   TO    REACH    THE    AnUS. 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM 


59 


which  he  states  that  the  rectum  was  divided  at  two  levels  by  annular, 
thin,  membranous  septa.  Bodenhamer,  Bushe,  Curling,  Molliere,  and 
Matas  all  confirm  these  reports,  and  Yoillemier  records  a  case  in  which 
the  rectum  was  divided  into  four  distinct  compartments  by  three  septa. 
Occasionally  there  will 
be  found  a  distinct 
fibrous  cord  that  ex- 
tends from  the  closed 
cul-de-sac  of  the  anus  to 
the  undescended  rectum 
(Fig.  42).  When  the 
rectum  descends  paral- 
lel with  the  anal  cul-de- 
sac,  and  yet  fails  to 
come  in  apposition  with 
it,  the  former  generally 
assumes  a  position  par- 
allel with  the  coccyx 
and  sacrum,  while  the 
latter  passes  upward 
alongside  of  the  pros- 
tate gland  or  vagina. 
In  these  cases  the  peri- 
toneal cavity  may  ex- 
tend downward  and 
backward  between  the 
two  occluded  ends  and 
render  it  impossible  to 
pass  from  one  to  the 
other  without  entering 

this  cavity.  In  the  interesting  case  described  by  Amussat  (Troisieme 
memoire,  Paris,  1843)  not  only  did  the  two  culs-de-sac  fail  to  meet 
one  another,  but  the  anal  cul-de-sac  opened  into  the  vagina  (Fig.  43), 
while  the  rectal  cul-de-sac  ended  a  short  distance  from  the  skin  just 
anterior  to  the  coccyx. 

It  has  been  claimed  that  these  multiple  septa  and  the  fibrous  cord 
leading  from  the  anal  cul-de-sac  to  the  enteron  are  indicative  of  the 
gut  having  been  patulous  in  foetal  life  and  become  occluded  through 
inflammatory  or  pathological  processes.  No  better  answer  to  this  theory 
can  be  given  than  that  of  Ball,  who  says: 

"  Unquestionably  this  cord  is  very  frequently  present,  but  it  by  no 
means  follows  that  its  presence  presupposes  a  pervious  intestine.  On 
the  contrary,  its  presence  can  be  shown  with  much  greater  probability 


Fig.  42.- 


-FiBEOUs  Cord  leading  from  the  Axus  to 
THE  Arrested  Eectcm. 


60 


THE  ANUS,  RECTUM,   AND   PELVIC  COLON 


to  have  dovolopmcntal  origin';  the  mesentcron  which  originates  from 
the  hypoblast,  as  before  mentioned,  forms  the  upper  portion  of  the  rec- 
tum, but  from  it  the  mucous  membrane  alone  is  developed,  a  layer  of 
mesoblast  subsequently  surrounding  the  tube  to  form  the  muscular  and 

other  external  portions 
of  the  intestinal  wall; 
consequently,  when  the 
develo})ment  of  the  cul- 
de-sac  of  mesenteron 
becomes,  from  any 
cause,  arrested,  it  does 
not  follow  that  the 
growth  of  the  other 
tunics  originating  from 
the  mesoblast  should 
be  arrested  also;  and 
when  there  is  no  mu- 
cous coat  to  be  sur- 
rounded, it  can  be  read- 
ily understood  how  this 
portion  of  mesoblast 
can  form  itself  into  the 
rounded  cord.  Again, 
we  must  remember  how 
exceedingly  rare  it  is 
for  a  mucous  canal  to 
be  obliterated  by  in- 
flammation, unless  at- 
tended with  a  very 
considerable  superficial 
loss  of  substance.  The 
only  instance  that  I  know  of  in  which  a  mucous  canal  is  obliterated 
during  the  process  of  development  in  the  human  subject  is  that  of 
the  urachus,  but  even  in  this  case  evidence  of  the  mucous  membrane, 
and  even  small  mucous  cavities,  are  still  found  in  the  cord  which 
forms  the  remains  of  this  foetal  structure.  I  have  recently  had 
an  opportunity  of  carefully  examining  a  case  of  this  kind  from  a 
patient  under  Professor  Bennett's  care  in  Sir  Patrick  Dun's  Hos- 
pital, in  which,  after  failure  to  meet  the  rectum  by  perineal  incision, 
a  colotomy  was  performed,  but  the  result  was  fatal.  In  this  instance 
there  was  a  very  firm  and  strong  cord  extending  from  the  cul-de-sac  to 
the  anal  portion ;  a  microscopical  examination  of  this  cord  showed  it  to 
be  composed  entirely  of  muscular  and  connective  tissue,  without  a  trace 


Fig.  43. — Rectum  desceniiino  Postekiok  to  the  Anus  and 
THE  Latter  opening  into  the  Vagina  (Aiiiussat). 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM  61 

of  mucous  membrane.  I  was  also  able  to  determine  another  important 
point  in  this  case.  If  the  anal  depression  is  composed  alone  of  procto- 
dseum,  it  is  obvious  that,  as  it  originates  entirely  from  the  epiblastic  layer 
of  the  embryo,  it  should  have  its  surface  covered  with  scaly  and  not 
columnar  epithelium.  I  consequently  obtained  a  small  piece  from  the 
fundus  of  the  anal  depression,  and  made  sections  of  it.  There  was  not 
a  trace  of  glandular  epithelium  to  be  seen  in  it,  so  that,  in  this  case  at 
any  rate,  the  conclusion  was  unavoidable  that  the  malformation  was  due 
to  the  fact  that  the  mesenteron  did  not  descend  low  enough  for  the  proc- 
todseum  to  meet  it ;  and  that,  I  believe,  is  the  explanation  of  the  major- 
ity, if  not  all  of  these  cases." 

In  addition  to  this  it  should  be  remarked  that  there  is  no  other  evi- 
dence of  previous  inflammation  in  the  intestinal  canals  of  such  children. 

Diagnosis. — The  diagnosis  of  these  cases  is  not  made  frequently 
until  some  days  after  birth.  The  normal  appearance  of  the  anus  does 
not  suggest  the  necessity  of  digital  examination,  and  it  is  not  until  sub- 
jective symptoms,  such  as  meteorism,  nausea,  and  faecal  vomiting,  begin 
that  the  real  condition  of  affairs  is  recognized.  The  anal  cul-de-sac 
under  such  circumstances  measures  from  1  to  1^  centimeter  (f  to  f  of 
an  inch)  in  depth,  and  frequently  less.  The  finger  is  arrested  at  once 
upon  attempts  to  introduce  it  into  the  rectum. 

If  the  enteron  is  close  down  to  the  cul-de-sac  of  the  anus,  with  the 
finger  in  the  latter,  when  the  child  cries  or  its  abdomen  is  pressed  upon, 
an  impulse  can  be  felt.  If,  however,  it  is  at  some  considerable  distance, 
or  if  it  descends  alongside  of  the  anal  canal,  such  an  impulse  will  be 
absent.  It  is  impossible  to  tell  accurately  by  any  method  the  distance  at 
which  the  rectum  will  be  found  from  the  anal  cul-de-sac,  and  the  fact  that 
the  peritoneal  cavity  may  intervene  between  the  two  renders  the  introduc- 
tion of  trocars  or  aspirating  needles  for  diagnosis  very  dangerous.  The 
only  method  to  determine  the  distance  is  by  actual  dissection,  and  this 
should  be  done  immediately  upon  recognition  of  the  condition  of  affairs. 

c.  Rectum  apening  into  some  Other  Viscus,  the  Anus  being  Present 
in  its  Normal  Position,  or  Absent. 

This  variety  is  by  far  the  most  frequent  of  all  malformations  of  the 
rectumand  anus.  It  comprises  about  50  per  cent  of  all  the  cases,  and 
the  large  majority  of  them  are  of  the  vulvo-vaginal  type. 

Leichtenstern  (Ziemssen's  Encyclopaedia,  vol.  vii,  p.  485)  says  that 
in  375  cases  of  rectal  malformation,  40  per  cent  were  of  this  variety; 
Bodenhamer  says  that  85  out  of  287  eases  belonged  to  this  class.  Wlien 
it  is  recalled  how  completely  the  anterior  is  shut  off  from  the  posterior 
part  of  the  perinseum  by  the  perineal  fasciae,  it  is  difficult  to  understand 
how  this  malformation  can  occur  so  frequently  in  male  subjects ;  on  the 
other  hand,  when  the  fact  is  recalled  that  the  rectum  and  genito-urinary 


62 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


apparatus  are  at  first  comprised  in  one  general  cloaca,  the  malforma- 
tion seems  likely  enough.  The  division  of  the  parts  not  having  been 
perfect,  some  small  communication  is  left,  and  through  this  the  secre- 
tions of  the  intestine  escape,  keep  it  patulous,  and  at  the  same  time 
prevent  that  weight  in  the  intestine  itself  which  would  naturally  cause 
it  to  sink  downward  and  come  in  contact  with  the  ascending  cul-de-sac 
of  the  proctoda?um. 

The  various  types  of  these  malformations  are  designated  according 
to  the  organ  with  which  the  rectum  communicates,  as  follows : 

Atresia  ani  vesica- 
lis:  Where  the  rectum 
opens  into  the  blad- 
der. 

Atresia  ani  ure- 
thralis:  "\Miere  the  rec- 
tum opens  into  the 
urethra. 

Atresia  ani  vagina- 
lis: Where  the  rectum 
opens  into  the  vagina. 
Atresia  ani  uteri- 
nge:  Where  the  rectum 
opens  into  the  uterus. 
Ati'esia  Ani  Vesi- 
calis. — When  the  rec- 
tum communicates 
with  the  bladder, 
whether  in  the  male 
or  female,  it  is  usually 
by  a  ver}^  narrow  canal 
lined  throughout  with 
mucous  membrane 
(Fig.  44).  In  females 
this  communication 
very  rarely  takes  place. 
In  males,  however,  it 
is  not  so  rare.  The 
opening  is  likely  to  be  at  the  trigone  or  higher  up  in  the  fundus. 
Where  the  opening  is  dovm  below  between  the  orifices  of  the  ureters, 
the  communication  is  generally  but  an  elongated,  narrow  canal,  run- 
ning diagonally  or  obliquely  through  the  walls  of  the  bladder,  and 
furnishing  only  a  very  restricted  outlet  for  the  contents  of  the  en- 
teron.    Where  the  opening  is  in  the  fundus  of  the  bladder  it  is  usually 


44. — Atresia  Axi  Vesicalis. 


MALFORMATIONS   OF  THE  ANUS  AND   RECTUM  63 

wider,  and  there  is  an  exit  for  the  intestinal  contents.  Tliere  have 
been  no  cases  reported  wliere  tliese  openings  have  involved  tlie  ureters 
or  their  exits. 

Diagnosis. — Tiie  diagnosis  of  these  cases  will  vary  in  difficult}'  ac- 
cording to  the  time  when  the  child  is  seen.  Usualh'  it  is  simple  enough ; 
the  absence  of  any  passages  frem  the  anus  will  suggest  an  examination. 
and  imperforation  will  thus  be  determined. 

The  appearance  of  the  dark  greenish  stain  of  meconium  in  the  urine 
is  sufficiently  characteristic  to  indicate  communication  between  the  rec- 
tum and  urinary  tract.  The  amount  of  this  matter  seen  in  the  urine  will 
indicate  to  a  greater  or  less  degree  the  size  of  the  opening  into  the  blad- 
der. Sometimes  the  quantity  is  so  small  as  to  barely  stain  the  urine, 
and  sometimes  it  is  so  abundant  that  the  urine  may  appear  to  be  pure 
meconium.  In  the  latter  class  of  cases  it  will  require  close  watching  to 
determine  whether  the  opening  is  in  the  bladder  itself  or  in  the  urethra. 

Ball  says,  "  The  fact  that  the  meconium  is  intimately  mixed  with 
the  urine,  and  it  only  appears  during  urination,  would  at  once  distin- 
guish this  variety  from  atresia  ani  urethralis."  This  is  very  logical  and 
clear  if  we  could  observe  the  child  during  the  urinary  passage,  but,  un- 
fortunately, this  act  generally  takes  place  during  the  absence  of  the 
physician,  while  the  child  is  asleep,  or  at  such  times  as  it  is  almost  im- 
possible to  observe  it,  and  consequently  we  have  to  draw  our  conclusions 
from  the  staining  of  the  diapers  and  clothing.  Constant  oozing  of  me- 
conium from  the  urethra  would  indicate  that  the  opening  was  not  in  the 
bladder,  but  it  does  not  prove  it.  The  rapidly  fatal  course  of  such  cases 
renders  dilatory  proceedings  in  the  diagnosis  of  this  condition  very  dan- 
gerous. Unless  the  condition  is  rapidly  relieved,  and  the  contents  of 
the  bowels  are  turned  away  from  the  bladder,  cystitis  will  result,  with 
subsequent  infection  of  the  ureters  and  kidneys,  and  the  child  will  die. 
On  the  other  hand,  if  the  opening  be  small,  as  it  usually  is  when  the 
lower  portion  of  the  bladder  is  invaded,  the  child  will  likely  succumb  to 
the  obstruction  of  the  intestine.  The  prognosis  in  such  cases  is  uni- 
formly bad.  The  operation  necessary  to  alter  the  condition  is  of  such 
miagnitude  that  most  children  are  unable  to  stand  the  shock;  on  the 
other  hand,  delay  subjects  the  victims  to  the  double  risk  of  intestinal 
obstruction  and  septic  infection  of  the  bladder  and  genito-urinary 
organs. 

Atresia  Ani  UrethmJis. — In  a  certain  number  of  cases  the  rectum 
opens  into  the  urethra  (Fig.  45).  This  condition  may  occur  in  the  male 
or  female,  but  it  is  much  more  frequent  in  the  male.  The  opening  may 
occur  at  any  point  along  the  whole  tract  of  the  urethra,  but  in  the  major- 
ity of  cases  it  occurs  in  the  membranous  portion.  The  communication 
is  generally  by  a  long,  narrow,  tubelike  channel,  passing  from  the  un- 


64 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


(l(,'scended  rectum  down  in  front  of  the  perineal  fascia,  and  opening  into 
the  posterior  surface  of  tlie  urethra.  Tliis  condition  is  not  so  serious  as 
the  preceding.  Rowan  reports  a  case  in  which  the  child  defecated 
through  the  penis  for  two  months  without  causing  any  signs  of  inflam- 
mation. Bodenhamer 
cites  a  number  of  cases 
in  which  the  victims 
have  lived  to  the  age 
of  twenty  -  one  and 
thirty  years  respect- 
ively, always  defeca- 
ting through  the  ure- 
thra. The  opening 
may  also  occur  at  the 
prepuce  or  frenum,  as 
in  the  case  of  Coley 
(Fig.  46). 

Diagnosis.  —  The 
diagnosis  of  this  con- 
dition is  somewhat 
more  simple  than  that 
of  atresia  ani  vesica- 
lis.  The  meconium 
or  ffecal  matter  passes, 
either  constantly  or 
at  stated  periods,  un- 
mixed with  urine,  and 
independent  of  the 
uriuar}-  act.  The  in- 
testinal contents  may 
be  found  escaping 
from  the  meatus  at  any  time,  and  no  evidence  of  cystitis  or  nephritis 
seems  to  develop.  If  the  communication  between  the  rectum  and  ure- 
thra be  very  small,  as  it  generally  is,  the  patient  may  suffer  from  ob- 
struction and  distention  of  the  bowels  and  all  the  consequent  compli- 
cations;  but  if  the  opening  be  fairly  large  there  may  be  no  subjective 
symptoms  whatever  and  no  indication  for  immediate  action.  Under 
such  circumstances  it  can  be  easily  understood  that  the  prognosis  in  such 
cases  is  much  more  favorable  than  in  the  preceding  class.  Moreover, 
the  fact  tnat  the  rectum  is  usually  low  down  in  the  perinaeum  in  these 
cases  makes  the  probable  outcome  of  an  operation  to  restore  the  anus  to 
its  normal  position  much  more  encouraging. 

Atresia  Ani  Vaginalis. — This  variety  furnishes  about  50  per  cent  of 


Fig.  45. — Atresia  Ani  Urethralis. 


MALFORMATIONS  OF  THE  ANUS  AND   RECTUM 


65 


all  the  cases  of  malformation  of  the  rectum.  The  frequency  with  which 
it  occurs  will  never  be  known^  inasmuch  as  it  produces  so  little  sub- 
jective inconvenience  that  patients  go  through  life,  perform  all  their  du- 
ties, marry,  bear  chil-  ___  

dren,  conduct  their 
households,  and  yet 
do  not  know  that  any 
deformity  exists. 

Buckmaster  reports 
a  case  of  a  woman 
thirty-two  years  of  age 
whose  rectum  opened 
into  the  vagina  near 
the  vulva,  and  who 
never  knew  that  she 
was  deformed  until  ex- 
amination for  a  uter- 
ine complaint  revealed 
the  condition.  The 
author  observed  in  the 
Philadelphia  Hospital 
a  prostitute  whose  rec- 
tum opened  by  a  sort 
of  valvular  orifice  into 
the  vagina,  and  who 
had  lived  to  the  age 
of  twenty-eight  years 
without  knowing  she 
was  in  any  way  de- 
formed (Fig.  47).  The 
communication  be- 
tween the  rectum  and  the  vagina  in  this  variety  of  malformations  may 
be  located  at  any  portion  of  the  vaginal  tract,  from  the  posterior  cul- 
de-sac  down  to  the  very  margin  of  the  vulva.  It  may  also  be  between 
the  anus  and  vagina,  thus  involving  practically  neither  organ. 

The  opening  may  be  very  small,  but  it  is  generally  of  sufficient  pro- 
portions to  allow  the  free  and  regular  escape  of  meconium  and  also  of 
fgecal  matter,  unless  the  latter  becomes  very  hard.  The  opening  may  be 
in  the  center  of  the  lower  end  of  the  rectum,  or  upon  the  side,  in  which 
case  the  organ  usually  ends  in  a  large,  dilated  cul-de-sac.  Sometimes  the 
opening  is  by  a  somewhat  elongated,  tubular  canal,  and  in  these  cases 
the  passage  of  faecal  matter  will  be  obstructed  as  soon  as  the  condition 
of  the  bowels  becomes  the  least  solid. 


Fig.  46. — Atresia  Aki  Peeputialis. 


66 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


Ball  reports  a  case  of  a  woman,  the  mother  of  six  children,  who  had 
this  form  of  malformation  all  her  life  without  the  slightest  inconve- 
nience. He  says:  "  The  anus  opened  into  the  lower  portion  of  the  va- 
gina, and  was  so  far  provided  with  a  sphincter  that  when  the  tip  of  the 

finger  was  introduced 
into  the  rectum  it  was 
tightlygrasped.  There 
was  not  the  least  in- 
continence, and  the 
howels  acted  regularly 
every  day.''  Eicord 
and  ]\Iodlin  have  re- 
ported similar  cases. 

Buckmaster  has 
collected  27  cases  of 
this  malformation,  the 
ages  running  all  the 
way  from  six  months 
to  forty  years.  He 
includes  also  in  this 
collection  ^Morgagni's 
case  at  one  hundred 
years  of  age. 

Caradec  (Gazette 
d'hopitaux,  1863)  has 
reported  the  case  of 
a  woman,  thirty-two 
years  of  age,  in  whom 
the  anus  and  vagina 
were  normal,  except 
that  from  the  margin 
of  the  vulva,  between  the  orifices,  there  was  an  opening,  slightly  oval 
and  large  enough  to  admit  two  fingers,  with  its  longest  diameter  an- 
tero-posterior.  This  opening  led  into  a  cul-de-sac  lined  with  mucous 
membrane,  which  at  its  entrance  offered  a  certain  resistance  like  that 
of  the  sphincter.  The  anterior  wall  between  it  and  the  vagina  was 
thicker  above  than  below.  The  posterior  wall,  on  the  contrary,  was 
thicker  below,  and  presented  a  fistulous  opening  large  enough  to  admit 
the  tip  of  the  finger  at  about  5  centimeters  {2  inches)  above  the  anus. 
The  woman  suffered  no  inconvenience  until  after  marriage,  when  faecal 
matter  began  to  pass  by  this  median  opening.  Caradec  termed  this 
malformation  a  second  vagina,  but  it  appears  that  it  would  have  been 
more  appropriately  termed  a  second  anus. 


Fig.  47. — Atresia  Axi  Vagix.^lis. 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM  67 

In  this  variety  of  malformation  the  anus  may  be  perfectly  formed,  or 
it  may  be  entirely  absent.  In  some  cases  there  is  an  opening  into  the 
vagina  as  well  as  a  perfectly  formed  connection  between  the  anus  and 
rectum.  In  these  cases  the  openings  into  the  vagina  may  never  be  sus- 
pected during  virginity.  I  have  heard  of  one  case  in  which  it  was  claimed 
that  the  passage  of  faecal  matter  through  the  vagina  was  due  to  trauma- 
tism during  the  sexual  act.  Closer  examination  proved  that  there  was, 
and  had  always  been,  a  sort  of  valvular  communication  between  the 
vagina  and  rectum,  lined  throughout  by  mucous  membrane,  and  that 
the  passage  of  fsecal  matter  through  the  vagina  had  only  been  prevented 
by  the  existence  of  a  close  hymen. 

Out  of  36  cases  of  malformations  not  included  in  the  statistics  so 
far  collected  by  others  the  author  finds  18  cases  of  this  variety.  The 
openings  into  the  vagina  are  usually  large  enough  to  admit  of  the  pas- 
sage of  ordinarily  formed  faecal  masses,  they  cause  little  inconvenience 
in  early  life  especially,  and  happily  do  not  demand  any  immediate  opera- 
tive interference.  The  child  will  grow  and  thrive,  and  if  the  opening  is 
not  large  enough  to  admit  of  the  passage  of  fsecal  masses,  it  can  be 
dilated  to  a  sufficient  extent  to  serve  all  practical  purposes,  until  the 
child  attains  an  age  at  which  surgical  operations  can  be  safely  per- 
formed. The  prognosis,  therefore,  in  such  cases  is  always  good.  There 
is  no  excuse,  however,  for  the  malformation  being  overlooked,  and  the 
child  allowed  to  reach  the  age  of  puberty  or  even  older  years  with  such 
a  deformity.  These  cases  emphasize  the  necessity  of  examining  the 
rectum  at  birth.  They  are  practically  harmless  if  recognized  and  treated 
properly,  but  if  neglected,  they  may  be  discovered  at  a  time  when  such 
a  deformity  would  wreck  the  life  of  the  woman. 

Atresia  Ani  Uterince. — Communication  between  the  uterus  and  rec- 
tum is  of  the  rarest  occurrence.  Only  two  cases  of  this  condition  have 
been  reported.  The  opening  in  one  of  these  cases  was  in  the  posterior 
lip  of  the  cervix,  in  the  other  the  site  was  not  mentioned.  ISTo  case  has 
been  reported  in  which  the  intestine  communicated  with  the  fundus  of 
the  uterus.  The  tracts  of  communication  in  the  cases  reported  have 
been  small  and  contracted,  only  allowing  a  feeble  escape  of  meconium 
through  the  vaginal  orifice.  In  each  case  the  gut  had  been  supposed 
to  open  into  the  vagina,  but  upon  dissecting  the  rectum  away  it  was 
found  to  enter  the  uterus  itself.  Such  cases  are  too  rare  to  merit  any 
lengthy  discussion.  They  are  simply  instances  of  the  freaks  of  nature 
which  are  seen  and  exhibited  as  monstrosities  in  museums  or  patho- 
logical laboratories. 

d.  Where  the  Rectum  and  Anus  are  Normal,  but  have  opening  into 
them  Other  Organs,  such  as  the  Ureters,  Vagina,  or  Uterus. 

Numerous  eases  of  this  form  of  malformation  have  been  reported. 


68  THE  AXUS,  RECTUM,  AND   PELVIC  COLON 

Bodenhamer  has  collected  7  cases  in  which  the  ureters  opened  into  the 
rectum  at  the  peritoneal  reflection,  and  9  cases  in  which  the  vagina 
terminated  in  the  rectum.  The  author  has  seen  1  case  in  which  the 
vagina  opened  into  the  rectum  at  about  1  inch  above  the  anal  orifice. 
The  uterus  in  this  case  opened  between  two  little  pillars  or  rudimentary 
vulvae.  There  was  absolutely  no  vaginal  formation  upon  the  external 
surface.  The  two  little  pillars  came  together  and  formed  a  median 
rhaphe  which  ran  backward  to  the  rectum.  The  uterus  could  be  easily 
felt  through  the  opening  into  the  vagina  from  the  rectum,  and  there  was 
no  cuJ-dc-sac  in  the  vagina  below  this  opening.  The  woman  suffered  no 
inconvenience  whatever  from  the  malformation,  and  declined  to  have 
any  operation  done  to  remedy  it.  Most  of  these  cases  occur  in  females, 
and  the  diagnosis  is  not  made  until  puberty.  In  the  case  which  the 
author  saw^  tlie  malformation  was  discovered  through  ineffectual  at- 
tempts at  sexual  intercourse.  When  opportunity  for  examination  is 
afforded  there  is  no  difficulty  in  diagnosing  such  malformations. 

Treatment. — While  the  method  of  operation  in  malformations  of  the 
anus  is  of  great  moment,  the  time  at  which  it  should  be  done  is  of  para- 
mount importance.  When  there  is  complete  atresia,  what  is  to  be  ac- 
complished must  be  done  at  once  in  order  to  afford  the  child  any  chances 
of  life.  On  the  other  hand,  in  those  cases  in  which  there  is  an  exit  for 
the  meconium  and  fluid  fa?ces^  a  more  conservative  course  ma}'  be 
adopted  until  the  child  has  grown  to  such  an  age  that  its  strength  will 
admit  of  whatever  surgical  manipulation  may  be  necessary.  If  the 
exit  for  the  meconium  be  very  small,  but  within  reach,  it  may  be 
gently  dilated,  even  though  it  be  in  bad  position,  until  the  child's  age 
will  justify  radical  surgical  interference. 

When  we  realize  how  much  at  times  depends  upon  the  life  of  a 
single  infant,  how  absolutely  lives  may  depend  upon  the  altering  of 
such  a  deformity  as  this,  and  how  dear  the  life  of  ever}-  child  is  to  its 
mother,  we  can  comprehend  how  necessary  it  is  for  every  physician  to 
be  prepared  to  act — act  promptly  and  wisely  in  such  an  emergency. 
The  prime  object  in  all  operations  for  malformations  of  the  anus  and 
rectum  is  to  give  an  exit  to  the  intestinal  contents.  Such  an  exit 
should  be  made  convenient,  permanent,  and  effective,  if  it  can  be  done 
without  jeopardizing  the  child's  life.  We  must  therefore  consider  first 
in  what  position  the  outlet  can  be  placed  with  the  greatest  safety  to 
the  child.  After  this  our  efforts  should  be  directed  toward  obtaining 
all  the  functional  activity  of  the  normal  organ;  therefore,  if  possible, 
the  opening  should  be  made  at  the  proper  time  in  the  normal  site  and 
as  far  as  possible  surrounded  by  the  normal  muscles  and  tissues. 

Operations  for  imperforate  anus  are  comparatively  modern.  The 
Greeks  and  Romans  seem  to  have  looked  upon  this  malformation  as 


MALFORMATIONS   OF  THE  ANUS  AND   RECTUM  69 

beyond  the  surgical  art.  The  first  instances  given  of  an  operation  for 
this  condition  is  that  of  Egineta  (Marius  Durand,  Gaz.  des  hopitaux, 
Paris,  December  1,  1894,  p.  1301),  who  in  the  seventh  century  relieved 
an  imperforate  amis  by  incising  the  sa?ptum.  This  method  was  the 
one  generally  adopted  from  that  time  on,  the  incision  being  dilated  by 
wax  bougies  or  by  the  finger.  It  is  remarkable  that  at  this  early  period 
the  line  of  scientific  surgical  technique  should  have  been  so  clearly 
foretold.  The  description  given  by  Durand  does  not  indicate  any  blind 
plunging  with  the  knife,  but  a  careful  incision  into  a  bulging  sac.  The 
operator  knew  and  saw  what  he  was  incising,  and  this  is  the  whole 
secret  of  the  modern  operation. 

Later  on  the  use  of  the  trocar  as  an  instrument  for  searching  after 
the  rectal  pouch  was  introduced,  and  for  a  long  time  the  method  of 
incision  was  little  used.  Children  falling  into  the  hands  of  general 
practitioners  were  subjected  to  the  trocar  operation,  and  most  of  them 
were  left  to  die  if  this  method  failed.  In  1831:,  Breschat  reported  he 
had  obtained  twelve  successful  results  b}'  the  method  of  j)erineal  inci- 
sion. This  popularized  the  method  in  France.  In  1787,  Sir  Benjamin 
Bell,  says  Bodenhamer,  advocated  a  dissection  through  the  peringeum, 
dilating  the  wound  by  the  use  of  his  finger,  and  searching  for  the  rectal 
ampulla  in  the  hollow  of  the  sacrum  with  the  trocar,  if  it  were  not 
found  lower  down.  Shortly  after  this  Dr.  John  Campbell,  quoted  also 
by  Bodenhamer,  successfully  performed  this  operation  in  Flemings- 
burg,  Ivy.  This  was  the  first  successful  operation  for  imperforate 
rectum  in  the  United  States.  Hutchinson  advocated  dissection  for 
1-J  to  2  inches,  and  after  this  trusted  to  the  trocar  only.  Dieffenbach 
made  a  crucial  incision  in  the  perina?um,  excised  the  triangular  flaps,  car- 
ried his  dissection  to  the  height  of  1  inch,  and  then  substituted  the  trocar 
for  the  knife  to  penetrate  upward  and  backward  into  the  hollow  of  the 
sacrum  until  the  rectal  j)ouch  was  tapped,  when  the  path  of  the  trocar 
was  dilated  and  the  meconium  allowed  to  escape.  "  If  this  procedure 
failed,  the  cannula  was  allowed  to  remain  in  situ,  and  a  piece  of  sponge 
was  forced  through  it  and  left  to  dilate  the  space  beyond.  If  after  this 
dilatation  the  pouch  could  not  be  reached,  colotomy  was  performed  " 
(Matas,  Surgical  Treatment  of  Imperforate  iVnus,  p.  7). 

For  a  long  time  no  attention  whatever  was  paid  to  the  preservation 
of  the  anus,  nor  was  any  attempt  made  to  do  anything  more  than  to 
give  the  contents  of  the  bowel  a  free  outlet  through  the  incisions  made. 
The  question  of  retraction  and  closure  of  the  incisions  was  first  brought 
up  and  discussed  by  Dionis  (Bodenhamer)  in  1740,  and  afterward  by 
Malyn  in  1840,  who  both  maintained  that  the  retraction  of  the  perineal 
muscles  would  efficiently  prevent  the  recontraction  of  the  wound.  This 
assertion  has  not  been  confirmed  by  surgical  experience. 


70  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

Eouz  (Gaz.  des  hopitaux,  1851,  vol.  vi,  p.  -434)  first  laid  special 
stress  upon  the  importance  of  preserving  the  sphincter  fibers  -while 
dissecting  the  perina^uni.  He  made  a  clean  surgical  dissection  by  the 
use  of  the  knife,  preserving  as  far  as  possible  whatever  rudimentary 
developments  of  the  external  sphincter  existed  in  the  perinanmi.  He 
still  followed,  however,  the  faulty  technique  of  allowing  the  meco- 
nium to  escape  through  the  open  perineal  wound  regardless  of  its 
depth,  thus  exposed  the  child  to  infection,  and  if  the  peritonanim  had 
been  opened,  allowed  the  contents  of  the  intestine  to  extravasate  into 
this  cavity. 

In  1835,  that  great  and  original  thinker,  Amussat,  published  in 
the  Gazette  de  Paris  an  article  entitled  "  The  History  of  Operation 
for  Artificial  Anus,  Practised  with  Success  by  a  New  Procedure  in  a 
Case  of  Congenital  Absence  of  the  Anus,  with  Some  Eeflections  upon 
the  Obliteration  of  the  Rectum."  From  this  operation  and  report 
begins  the  scientific  and  radical  treatment  of  malformations  of  the 
anus  and  rectum.  In  this  paper  also  was  first  thrown  out  the  sugges- 
tion that  room  for  operative  procedures  about  the  rectum  and  pelvis 
might  be  obtained  by  the  removal  of  the  coccyx,  thus  for  the  first  time 
pointing  out  the  possibility  of  the  sacral  or  Kraske  operation  and  all 
its  modifications. 

It  seems  that  the  French  and  Germans  have  utterly  forgotten  the 
suggestion  of  Amussat  in  all  their  writings  on,  and  developments  of, 
the  sacral  route.  Verneuil,  writing  in  1873,  stated  that  the  possibility 
and  usefulness  of  resection  of  the  coccyx  had  occurred  to  him  as  far 
back  as  1853,  but  he  had  not  put  it  into  practise,  owing  to  want  of 
opportunity,  until  1870.  In  this  valuable  paper,  so  often  referred  to, 
we  can  recognize  the  suggestion  of  Amussat,  who  was,  no  doubt,  original 
in  his  work  and  thought,  if  not  the  pioneer  in  this  line.  The  chief 
feature,  however,  of  Amussat 's  recommendation  was  not  the  removal 
of  the  coccyx  to  gain  space  for  operation;  it  was  the  fact  that  he  dis- 
sected the  rectum  loose  and  brought  it  do\\Ti,  suturing  the  mucous 
membrane  of  the  gut  to  the  skin  at  the  margin  of  the  anus,  if  an  anus 
existed,  or  at  the  nearest  point  to  the  normal  position  of  the  latter 
to  which  he  could  bring  the  undescended  rectum.  This  furnished  an 
exit  to  the  intestinal  contents  upon  the  outside,  which  was  sealed  off 
from  the  wound  by  a  close  apposition  of  the  parts.  He  advocated  that 
the  rectum  should  be  freely  detached  from  all  its  surroundings  so  as 
to  bring  it  down  to  its  normal  position,  if  possible,  without  any  ten- 
sion; and  that  it  should  be  dravm  out  of  the  wound  and  emptied  of 
its  meconium  before  suturing.  He  advised  the  free  and  wide  dissec- 
tion of  the  perinaeum,  as  well  as  the  removal  of  the  coccyx,  if  neces- 
sary, to  accomplish  this.     He  also  advised,  where  it  was  requisite,  to 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM       Tl 

open  the  peritoneum,  as  this  could  he  clone  witli  as  little  danger 
through  the  pelvic  route  as  through  the  abdominal.  From  his  day  to 
the  present  time  all  methods  of  operation  upon  imperforate  ani  and  mal- 
formations of  the  rectum  have  been  based  upon  these  j^ropositions  of 
Amussat,  and  barring  the  introduction  of  aseptic  surgery,  there  has 
been  no  radical  improvement  in  the  method  which  he  proposed.  It 
is  said  by  some  authors  that  Amussat's  proposition  to  remove  the  coccyx 
was  not  to  gain  space,  but  in  order  to  afford  a  position  higher  up  and 
nearer  the  undescended  rectum,  to  which  the  latter  could  be  attached 
in  case  of  difficulty  in  bringing  it  down  to  the  normal  anus. 

"What  he  says  is:  "  After  having  resected  the  cocc^^s,  in  order  to  gain 
more  room  for  reaching  the  rectum,  the  space  thus  left  will  afford  a 
convenient  position  to  attach  the  latter  in  case  it  can  not  be  brought 
down  to  the  normal  position."  To  those  interested  in  the  development 
of  modern  technique  for  operations  upon  malformations  of  the  rectum 
and  anus,  the  reading  of  Goyraud's  articles  published  in  1856  (Gaz. 
med.  de  Paris,  pp.  509,  5$-i,  538,  601,  and  639),  and  Matas's  brochure, 
1897,  is  suggested. 

A  discussion  of  treatment  under  the  individual  types  of  malforma- 
tion has  been  avoided  for  the  reason  that  such  discussion  would  neces- 
sitate numerous  repetitions  with  regard  to  technique.  We  shall  there- 
fore consider  the  treatment  in  general,  and  point  out  its  application 
to  each  particular  form  of  malformation  mentioned  in  the  text.  In  the 
first  place,  then,  let  us  study  those  malformations  of  the  anus  and 
rectum  in  which  there  is  absolute  occlusion.  In  such  cases  it  is  neces- 
sary that  immediate  and  radical  operative  interference  should  be  under- 
taken. The  policy  of  waiting  for  a  da}'  or  two  to  see  if  spontaneous 
opening  will  not  occur,  or  with  the  view  of  allowing  the  child  to  gain 
strength,  is  most  fallacious.  "^Tiere  there  is  no  aperture  at  the  time 
of  birth  there  is  little  or  no  probability  that  it  will  show  itself  after- 
ward. The  child  at  birth  is  Cjuite  as  able  to  withstand  surgical  shock 
as  it  is  two  or  three  days  later  after  suff'ering  from  intestinal  obstruc- 
tion. Statistics  of  the  operations  performed  within  the  first  twenty- 
four  hours  show  a  decided  advantage  over  those  done  at  later  periods. 
In  general,  we  may  say  the  earlier  the  operation  in  all  cases  of  complete 
occlusion,  the  more  favorable  will  be  the  prognosis.  Every  hour's 
delay,  therefore,  is  a  waste  of  valuable  time.  The  complete  absence 
of  the  anus  is  no  indication  whatever  of  the  distance  at  which  the 
rectum  will  be  found;  indeed,  its  distance  is  generally  in  inverse  pro- 
portion to  the  development  of  the  anus.  Therefore,  the  amount  of  mal- 
formation found  in  the  anus,  or  its  entire  absence,  will  not  indicate 
in  any  manner  the  difficulty  of  the  operation. 

The  prognosis  in  a  case  depends  largely  upon  the  facility  with  which 


72  THE  ANUS,   RECTU3I,   AND  PELVIC  COLON 

the  rectum  is  found  and  brought  into  position,  but  this  can  not  be 
stated  with  any  certainty  except  after  operation.  It  is  tlie  duty  of 
the  surgeon  to  explain  clearly  to  the  family  that  life  is  impossible 
without  such  an  operation,  and  that  no  possible  advantage  can  accrue 
from  delay.  The  operation  itself  should  be  undertaken  with  the  great- 
est aseptic  precautions.  Xo  anaesthetic  should  be  given  to  children  of 
this  age.  They  bear  pain  well,  and  the  danger  of  shock  from  this 
is  less  than  that  of  local  or  general  anaesthesia. 

Before  beginning  the  incision,  it  is  well  to  use  every  method  at 
our  command  to  determine  if  possible  the  position  of  the  rectum.  The 
skin  at  the  normal  position  of  the  anus,  or  at  some  portion  of  the 
perinanim,  may  be  of  a  greenish  tinge,  due  to  the  transmission  of  the 
green  color  of  the  contained  meconium  through  the  attenuated  tissue. 
There  may  be  bulging  at  some  point  in  the  perinsum,  indicating  the 
near  ai)proach  of  the  rectum.  ^Yith  a  hand  upon  the  perineum  and 
pressure  on  the  abdomen,  one  may  sometimes  feel  an  impulse  from 
the  rectal  pouch  when  the  child  is  caused  to  cry  or  strain;  percussion, 
while  the  stethoscope  is  applied  to  the  perina?um,  may  also  aid  us  to 
determine  the  proximity  and  site  of  the  rectum. 

Other  methods,  such  as  introducing  a  sound  into  the  vagina,  the 
bladder,  or  the  urethra,  have  been  advised;  but  the  consensus  of  ojoinion, 
among  those  who  have  seen  the  most  of  this  sort  of  surgerv,  is  that 
they  are  without  any  material  benefit.  Finally,  and  that  which  has 
been  the  most  frequently  used  and  advised,  the  introduction  of  an 
aspirating  needle,  or  a  trocar,  into  the  perinaeum,  and  backward  into  the 
hollow  of  the  sacrum,  may  be  used  to  determine  the  position  of  the 
rectum.  So  far  as  this  operation  is  concerned,  exploratory  needles 
are  dangerous  instruments.  In  their  introduction  through  the  per- 
inaeum into  the  rectal  pouch,  even  if  the  latter  can  be  found,  one  can 
never  be  assured  that  they  do  not  pass  through  a  diverticulum  of  the 
peritoneal  cavity,  and  upon  being  withdrawn  will  allow  the  meconium 
to  escape  into  this  cavity,  exposing  the  child  to  all  the  dangers  of 
septic  peritonitis.  The  aspirating  needle  is  slightly  less  dangerous  than 
the  trocar.  A  fine  one  may  be  introduced  into  a  bulging  point,  or  at 
a  place  where  impulse  can  be  felt,  and  meconium  withdrawn;  then, 
without  withdrawing  it,  one  may  dissect  down  along  its  track  and  open 
the  gut.  Unfortunately,  however,  the  tension  in  all  these  blind  rectal 
pouches  is  so  great  that  even  the  sticking  of  a  needle  into  them  may 
cause  rupture  and  extravasation  of  meconium  into  the  peritonaeum  or 
track  of  the  aspirating  needle.  Beyond  these  cases,  in  which  the  bulg- 
ing or  impulse  are  perceptible,  no  search  with  the  trocar  or  aspiratmg 
needle  should  ever  be  made;  and.  indeed,  in  these  very  cases,  the  advan- 
tages are  altogether  with  the  plan  of  careful,  patient  dissection. 


MALFORMATIONS  OF   THE  ANUS  AND  RECTUM  T3 

After  having  determined  as  far  as  possible  the  position  of  the  rectal 
pouch;,  the  operation  can  be  undertaken  at  once.  In  cases  in  which 
there  is  no  anus,  one  should  endeavor  to  make  one.  A  straight  incision 
should  be  made  from  the  point  at  which  the  anterior  margin  of  the 
anus  would  naturally  apj^ear  (Fig.  4),  back  through  the  skin  and  sub- 
cutaneous tissues  to  the  tip  of  the  coccyx.  If  there  be  a  rudimen- 
tary anus  the  incision  should  begin  at  its  posterior  margin.  Having 
cut  through  the  skin  and  subcutaneous  tissue,  we  come  down  upon  the 
external  sphincter  muscle,  or  the  fibrous  band  which  takes  its  place 
when  absent.  In  the  majority  of  cases  in  which  the  anus  is  altogether 
absent,  the  sphincter  is  absent  also.  At  any  rate,  whether  fibrous  or 
muscular  tissues  exist  at  this  point  they  should  be  divided  by  a  blunt 
periosteal  elevator  instead  of  by  incision,  and  pulled  gently  apart.  After 
this  the  dissection  can  be  carried  upward  as  far  as  is  necessary  in  search 
for  the  undescended  rectum.  This  median  incision  should  be  invari- 
able; whether  the  impulse  from  the  rectum  is  felt  to  one  side,  anterior 
or  posterior  to  the  anus,  the  incision  and  the  division  of  the  sphinc- 
ter should  always  be  the  same.  The  dissection  in  searching  for  the 
rectum  should  be  carried  upward  and  backward  in  the  hollow  of  the 
sacrum  in  order  to  avoid  wounding  the  bladder  or  other  pelvic  organs. 
When  the  rectum  has  been  found,  an  effort  should  be  made  to  loosen 
the  pouch  fromi  all  its  attachments,  and  bring  it  out  through  the  open- 
ing which  has  been  made,  with  a  view  of  preserving  the  functional 
activity  of  the  anus.  This  should  be  done,  if  possible,  without  open- 
ing the  pouch.  Sometimes,  however,  it  will  be  found  impossible  to 
bring  it  down  into  the  wound  until  its  distention  has  been  reduced. 
Just  here  we  have  the  one  useful  indication  for  the  trocar.  When 
the  gut  has  been  freed  from  its  attachments,  and  it  is  found  insuffi- 
ciently long  to  be  brought  down  into  the  wound,  the  trocar  may  be 
inserted  and  the  meconium  drawn  off  entirely  outside  of  the  wound, 
thus  reducing  the  distention  and  lengthening  the  gut.  After  this  it 
will  generally  be  found  that  the  latter  can  be  brought  down  into  the 
wound  without  difficulty.  Sterilized  gauze  should  be  packed  around 
the  trocar  and  well  into  the  wound  during  this  process,  and  the  gut 
held  firmly  by  pressure  forceps.  It  is  a  better  plan,  however,  if  the 
gut  can  be  brought  outside  of  the  wound,  to  do  so,  and  having  packed 
the  edges  of  the  wound  with  gauze,  incise  it  as  freely  as  necessary  to 
afford  an  exit  for  the  contained  meconium. 

The  suggestion  of  Matas  that  a  running  stream  of  saline  or  other 
aseptic  solution  be  carried  over  the  parts  during  this  process  of  empty- 
ing the  rectal  pouch  seems  to  be  contrary  to  the  opinion  of  most 
surgeons.  It  is  better  to  use  simple,  dry  sponges,  thus  keeping  the 
parts  free  from  the  discharge. 


74:  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

Having  emptied  the  rectal  pouch  of  its  contents,  the  next  step 
in  the  operation  is  to  fix  it  in  its  normal  site  if  possible.  This  is  done 
by  suturing  the  mucous  membrane  to  the  cut  edges  of  the  skin  at  the 
site  of  the  normal  anus.  It  is  necessary  to  emphasize  here  that  the 
sutures  are  not  placed  in  the  peritoneal  or  muscular  walls,  but  in  the 
mucous  membrane  of  the  gut.  The  intention  is  to  seal  off  the  perineal 
wound  from  contact  with  the  fsecal  discharges,  to  bring  the  inner  layer 
of  the  gut  upon  the  outer  surface  of  the  skin  so  that  the  alvine  dis- 
charge will  be  carried  entirely  outside  of  the  wound.  If  there  be  super- 
fluous mucous  membrane,  acting  somewhat  as  a  prolapse  of  the  rectum, 
it  would  be  all  the  better^  so  far  as  this  intent  is  concerned. 

Vincent  has  advised  that  when  the  anus  must  be  made  at  some  other 
than  the  normal  position,  it  would  be  well  to  dissect  two  elliptical 
flaps  of  skin  from  either  side  of  the  wound  and  carry  the  mucous  mem- 
brane outward  over  the  edges  of  the  wound,  uniting  it  to  the  skin  at 
the  points  from  which  these  flaps  have  been  dissected,  thus  affording 
a  larger  area  of  denuded  tissue  for  the  attachment  of  the  gut,  and  at 
the  same  time  carrying  the  discharge  from  the  intestinal  canal  more 
thoroughly  away  from  the  deeper  section  of  the  wound.  This  is  a  most 
excellent  suggestion.  "When  the  gut  has  been  brought  down  and  sewed 
in  its  normal  position  at  the  anus,  the  closing  of  the  posterior  part 
of  the  perineal  wound  should  be  made  with  sutures  passed  deep  enough 
to  take  in  the  fibers  of  the  external  sphincter  and  hold  them  in  position 
until  reunited.  Silkworm  sutures  or  chromicized  catgut  are  most  suita- 
ble for  this  purpose.  With  regard  to  the  sutures  to  be  used  in  fasten- 
ing the  gut  to  the  margin  of  the  skin,  authorities  differ;  a  good  size 
sterilized  catgut  is  preferred:  first,  because  it  has  less  tendency  to  cut 
through  the  tender  membranes  than  does  any  other  form  of  suture;  sec- 
ond, it  does  not  have  to  be  removed;  and  third,  after  it  is  introduced 
it  swells  and  stops  up  the  holes  through  which  it  passes  more  or  less 
effectually  until  it  has  become  practically  absorbed.  Silkworm  gut  and 
silver  wire  are  stiff  and  too  unpliable  to  bring  the  points  into  close 
apposition. 

The  author  prefers  a  broken,  continuous  suture.  By  this  is  meant 
a  continuous  suture  carried  half-way  around  the  rectum  and  tied,  and 
then  a  second  one  carried  around  the  other  half.  The  advantage  of 
this  suture  is  that  it  more  completely  seals  off  the  wound  from  the 
rectal  discharges  than  do  the  interrupted  sutures.  Its  being  broken 
in  two  places  gives  the  anus  more  opportunity  for  dilating,  and  pre- 
vents the  suture  acting  as  a  purse-string  to  contract  the  orifice.  AYhere 
there  is  any  difficulty  or  tension  necessary  to  bring  the  gut  down  to 
the  margin  of  the  anus,  this  may  be  relieved  by  passing  an  anchoring 
suture  through  the  external  wall  of  the  gut  or  the  mesorectum,  if  it 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM  75 

can  be  found,  and  out  through  the  skin,  tying  it  over  a  y-ad  of  gauze, 
and  thus  taking  the  traction  off  the  sutures  in  the  mucous  membrane. 

The  dressings  should  be  of  soft  absorbent  gauze  moistened  with 
boric-acid  solution,  and  held  in  place  by  a  diaper.  The  abdomen 
should  be  incased  in  a  snug  roller-bandage  to  avoid  straining. 

Cases  in  which  the  Bectum  is  arrested  High  Up  in  the  Pelvis. — The 
incision  and  methods  of  suturing  the  gut,  when  found,  are  applicable 
to  all  forms  of  imperforate  anus.  TTe  come  now  to  the  study  of  those 
forms  in  which  the  rectum  is  removed,  or  arrested,  in  its  descent  at 
a  greater  or  less  distance  from  the  cul-de-sac  of  the  anus.  In  such 
cases  the  anus  may  be  absent,  or  it  may  be  perfectly  developed,  ending 
in  a  cul-de-sac  about  1  to  1-|  centimeter  (about  ^  inch)  in  depth.  The 
method  of  dealing'with  this  cul-de-sac  will  be  described  later,  as  we  de- 
sire at  this  time  to  devote  out  attention  to  the  undescended  rectum. 

In  order  to  thoroughly  comprehend  the  difficulties  of  searching  for 
the  rectal  pouch,  it  is  necessary  to  understand  the  space  in  Avhich  the 
operation  must  be  performed.  This  space  is  outlined  by  the  tuber 
ischii  upon  each  side,  the  scrotum  in  front,  and  the  coccyx  behind. 
The  distance  in  infants  between  the  tuber  ischii  is  normally  about  1-| 
to  2  centimeters  (f  to  f  of  an  inch),  and  does  not  differ  materially 
in  the  sexes.  That  from  the  scrotum  to  the  coccyx  averages  from  4 
to  4^  centimeters  (IjV  ^^  If  inch),  and  from  the  posterior  commis- 
sure of  the  vagina  to  the  coccyx  in  girls  about  3  to  4  centimeters 
(ItV  to  IjV  inch).  The  distance  from  the  anus,  when  developed,  to 
the  tip  of  the  coccyx  would  average  about  1-|  centimeter  (f  of  an 
inch).  With  these  measurements  in  view,  we  can  understand  that  the 
operative  field  or  space  would  be  embraced  in  an  elliptical  figure 
with  a  maximmn  length  of  4  centimeters  (1  3^  inch)  and  a  maximum 
breadth  of  2  centimeters  (|  of  an  inch).  The  depth  of  the  pelvis,  or 
rather  the  distance  from  the  tip  of  the  coccyx  to  the  promontory  of 
the  sacrum,  is  about  6  centimeters  (2f  inches).  The  distance  from 
the  perina?um,  at  which  the  peritoneal  cul-de-sac  is  found,  varies  con- 
siderably, but  it  may  be  stated  that  in  general  this  pouch  in  females 
is  about  2  centimeters  (f  of  an  inch),  and  in  males  it  is  2J  to  3  centi- 
meters (1  inch  to  1-j^  inch).  It  should  be  borne  in  mind  that  these 
are  normal  measurements,  and  that  in  cases  of  malformation  of  the 
anus  and  rectum  there  is  also  likely  to  be  some  malformation  of  the 
pelvic  frame.  This  malformation  generally  takes  the  form'  of  abnormal 
contraction,  and  the  space  for  operative  procedure  is  thus  reduced.  It 
is  well  to  mention  here  also  the  fact,  shown  by  Cripps,  that  where  there 
is  malformation  of  the  anus  and  rectum  there  is  likely  to  be  some 
abnormal  distribution  of  the  peritoneal  cul-de-sac.  This  may  pass 
downward  and  backward  almost  to  the  skin  near  the  tip  of  the  coccyx. 


Y6 


THE  ANUS,   RECTUM,   AND  PELVIC  COLON 


thus  separating  the  ends  of  the  i)rocto(hi'uin  and  the  enteron  by  a  true 
peritoneal  cavity  (Fig.  48).  Such  an  arrangement  of  the  peritoneum 
\yould  render  it  impossible  to  introduce  an  aspirating  needle  or  trocar 
from  the  anus  into  the  rectum  without  passing  directly  through  it,  and 
would  necessitate  the  subsequent  infection  of  that  cavity  when  the 

instrument  was  with- 
drawn. As  it  is  im- 
possible to  predicate 
such  a  condition  or  its 
absence  before  opera- 
tion, one  should  abso- 
lutely limit  the  use  of 
the -trocar  to  carrying 
the  fluid  contents  of 
tlie  rectum  beyond  and 
outside  of  the  wound, 
after  the  organ  has 
been  found,  and  it  is 
impossible  to  bring  it 
outside  of  the  wound 
before  emptying  it.  It 
can  be  readily  seen 
from  the  measure- 
ments above  given 
tluit  space  for  opera- 
tive manipulation  is 
very  limited,  and  with 
the  bladder,  uterus, 
and  other  pelvic  or- 
gans in  position,  the 
operator  will  have  to 
be  very  careful  in 
working  in  so  small  a 
space  lest  he  injure 
them.  The  chief  space  of  the  pelvis  thus  left  for  operative  manipula- 
tion is  in  the  hollow  of  the  sacrum,  and  in  order  to  reach  this,  one  has 
to  dissect  backward  and  upward  around  the  point  of  the  coccyx,  work- 
ing largely  by  feeling  and  not  by  sight. 

The  methods  which  have  been  devised  to  increase  this  space  have 
been  numerous  and  ingenious.  The  first  was  that  of  Amussat,  which  con- 
sisted in  removal  of  the  coccyx.  This  operation,  simple  in  itself  and  very 
easy  to  perform  in  children,  is  objectionable  because  it  takes  away  the 
normal  attachment  of  the  anal  and  rectal  muscles;  it  also  removes  the 


Fig.  4S. — Malformation   in  which  the   Pekitoneal   (.'ll- 

DE-SAC    EXTENDS    BETWEEN    THE    BlIND    EnuS    OF   THE    Rec- 

TUM  AND  Anus. 


MALFORMATIONS  OP  THE  ANUS  AND  RECTUM  Y7 

support  to  the  lower  end  of  the  rectum,  and  thus  invites  prolapse  and 
posterior  rectocele.  Carrying  this  operation  one  step  farther,  we  have 
the  various  modifications  of  the  Kraske  or  sacral  operation.  It  is  not 
necessary  to  describe  them  here^  further  than  to  say  that  whatever 
portion  of  the  sacrum  it  is  thought  wise  to  remove  can  be  done  by  a 
strong  pair  of  scissors  without  the  use  of  a  chisel  or  bone-cutting  instru- 
ment. The  danger  of  injury  to  the  nerves,  shock,  and  the  removal  of 
rectal  supports  and  muscular  attachments  are  the  objectionable  features. 

If  one  could  say  positively  when  he  begins  that  the  rectum  was  high 
up,  and  the  space  would  have  to  be  increased,  there  is  no  doubt  but 
that  the  Eydygier  operation,  described  in  the  chapter  on  excision  of 
the  rectum,  would  be  a  practical  and  safe  procedure.  Such  a  radical 
operation,  however,  would  not  be  justified  unless  we  had  some  absolute 
assurance  that  the  rectum  was  high  up  in  the  pelvis. 

A  more  conservative  plan  is  that  of  Vincent,  who  takes  advantage 
of  the  soft,  cartilaginous  condition  of  the  bones  at  this  period,  and 
splits  the  coccyx  and  the  lower  part  of  the  sacrum  through  their  center 
with  a  large  pair  of  scissors;  then  the  edges  of  the  wound  are  re- 
tracted and  ample  space  for  operative  manipulation,  and  a  good,  free 
view  of  the  whole  pelvic  cavity  are  afforded.  After  the  rectum  has 
been  found  and  brought  into  its  normal  position,  deep  sutures  are 
used  to  bring  the  bones  and  tissues  together,  and  thus  the  pelvic  frame 
is  absolutely  restored.  This  operation,  as  described  by  Matas,  Vincent, 
and  others,  has  proved  entirely  successful,  and  the  ultimate  results 
have  been  most  satisfactory.  Theoretically  there  is  one  objection  to 
it,  and  that  is  in  cases  in  which  the  rectum  can  not  be  brought  down 
to  its  normal  position,  and  must  be  attached  to  the  upper  end  of  the 
wound,  it  will  necessarily  bring  the  gut  out  between  two  flaps  of  bone. 
In  such  instances  the  bone  flap  or  Kraske  operation  would  be  more 
satisfactory.  Nevertheless,  in  the  Vincent  operation  there  would  be 
little  difficulty  in  peeling  out  the  cartilaginous  section  of  the  sacrum 
or  coccyx  so  as  to  make  the  flap  soft  upon  one  side  in  such  an  emer- 
gency, and  the  ultimate  results  would  be  the  same  as  by  the  other  meth- 
ods. The  space  for  operative  manipulation  having  thus  been  materially 
enlarged,  the  succeeding  steps  of  the  operation  will  be  in  full  view  and 
comparatively  simple.  Dissection  should  be  carried  upward  into  the 
hollow  of  the  sacrum  to  the  depth  of  5  or  6  centimeters  (2  or  2|  inches). 
At  the  same  time  careful  palpation  should  be  made  with  the  finger  in 
the  wound  to  elicit,  if  possible,  any  impulse  from  the  child's  crying 
or  from  pressure  upon  the  abdomen  by  an  assistant.  Where  such 
impulse  is  felt  it  arises  from  the  rectal  pouch  or  from  some  loop  of 
sigmoid,  and  dissection  should  be  made  in  this  direction.  At  this  stage 
of  the  operation  it  is  best  to  introduce  a  sound  into  the  bladder  of 


78  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

the  male  or  the  vagina  of  the  female,  in  order  to  determine  the  exact 
location  of  these  organs,  and  thus  avoid  wounding  them.  The  fibrous 
cord  which  sometimes  leads  from  the  imperforate  anus  up  to  the  rectal 
pouch  (Fig.  4:2),  when  found,  should  always  be  kept  in  view  and  fol- 
lowed closely,  as  it  is  a  certain  guide  to  the  rectal  pouch.  WTiere  this 
cord  does  not  exist  we  must  depend  upon  careful  dissection  in  order 
to  find  the  gut.  When  it  is  not  found  in  the  hollow  of  the  sacrum 
after  having  dissected  upward  for  the  space  of  5  or  6  centimeters  (2 
or  2f  inches)  from  the  margin  of  the  anus,  dissection  in  this  line  is 
no  longer  advisable;  but  the  operator  should  carry  his  incision  through 
the  soft  cellular  tissues  forward  and  upward,  entering  the  peritoneal 
cavity  at  once,  if  the  rectal  pouch  is  not  reached  before  doing  so.  The 
dangers  in  this  operation  are  not  from  opening  the  peritoneal  cavity, 
but  from  allowing  the  intestinal  contents  to  escape  into  it.  The  author 
would  not  advise  opening  the  peritoneal  cavity  unnecessarily  under  any 
conditions,  and  much  less  so  in  a  feeble  child;  but  the  old  dread  of 
invading  this  cavity  has  caused  the  waste  of  much  valuable  time,  and 
has  been  the  cause  of  death  in  many  cases.  Therefore,  when  the  rectal 
pouch  has  not  been  found^,  after  a  reasonable  dissection  in  the  hollow 
of  the  sacrum,  the  immediate  and  free  opening  of  the  peritona3um  is 
advised.  When  this  has  been  done  the  search  for  the  rectal  pouch  is 
simple  enough.  If  it  is  distended  and  tense,  and  in  the  pelvic  cavity 
at  all,  it  will  be  easily  felt.  It  may  be  attached  to  the  promontory  of 
the  sacrum  off  to  one  side  of  this  bone,  or  it  may  be  fioating  loose 
in  the  peritoneal  cavity.  In  the  latter  instance  it  is  generally  easily 
brought  down,  and  can  be  attached  to  some  portion  of  the  wound  with- 
out much  tension.  When,  however,  it  is  attached  to  the  promontory 
of  the  sacrum,  or  to  its  side  high  up,  the  process  of  bringing  it  down 
is  much  more  difficult.  The  difficulty  lies  in  the  fact  that  the  rectal 
pouch  is  covered  over  and  bound  down  to  the  bone  by  a  peritoneal  fold 
which  entirely  envelops  the  lower  end,  and  is  really  the  cause  of  its 
non-descent. 

The  splitting  of  this  peritoneal  covering,  and  the  enucleation  of  the 
rectal  pouch  so  as  to  bring  it  down  to  the  margin  of  the  wound,  has 
been  attempted  with  some  success.  This,  however,  is  a  most  difficult 
procedure,  and  the  author  questions  very  much  if  it  would  not  be  wiser 
to  do  an  inguinal  colotomy  as  soon  as  such  a  condition  of  affairs  is 
found  to  exist,  or,  if  possible,  bring  a  loop  of  the  sigmoid  flexure  down 
and  attach  it  to  some  point  of  the  perineal  wound.  AVhen  the  rectum 
is  found,  the  greatest  care  must  be  exercised  to  loosen  its  attachments 
and  drag  it  down  so  as  not  to  rupture  the  inferior  mesenteric  artery, 
and  thus  obliterate  the  blood  supply  to  the  parts.  When  it  has  been 
brought  down  in  the  perineal  wound  at  the  normal  position  of  the  anus. 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM  79 

or  higher  up,  if  necessary,  the  peritonaeum  should  be  closed  by  gauze 
packing  before  the  gut  is  opened  to  allow  the  escape  of  the  meconium. 
If  the  development  of  the  rectal  pouch  is  so  short  that  it  can  not  be 
brought  outside  of  the  peritoneal  cavity,  then  this  cavity  should  be 
closed,  the  perineal  wound  packed  off,  and  inguinal  colotomy  done  at 
once.  Sometimes,  where  the  rectum  can  not  be  found  by  perineal  inci- 
sion and  dissection,  and  inguinal  colotomy  has  been  done,  it  will 
descend  at  a  later  period,  and  the  operator  will  be  able  finally  to 
approximate  the  anus  and  rectum  at  their  normal  positions. 

The  fixation  of  the  rectum  in  this  form  of  malformation  is  prac- 
tically the  same  as  that  in  simple  imperforate  anus.  The  mucous  mem- 
brane should  be  sutured  to  the  skin  at  the  normal  anus  if  possible,  and 
if  not  possible,  it  should  be  sutured  at  the  lowest  point  of  the  perineal 
wound  to  which  it  can  be  brought  without  too  great  tension. 

An  interesting  case  illustrative  of  the  conditions  just  mentioned  is 
reported  by  Kronlein  (Berlin,  klin.  Woch.,  1879,  p.  136).  He  opened 
the  peritoneal  cavity  after  a  dissection  of  3  inches  without  finding  the 
rectal  pouch.  The  finger  end  introduced  in  the  cavity  failed  to  find 
the  missing  cul-de-sac,  and  he  immediately  attempted  inguinal  colotomy. 
Here  again  he  met  with  a  difficulty  in  the  close  attachment  of  the  colon 
to  the  lumbar  region,  which  absolutely  prevented  his  bringing  the  colon 
up  into  the  abdominal  wound.  He  was  therefore  compelled  to  bring 
up  and  open  the  next  and  most  distended  loo23  of  intestine.  He  does 
not  state  whether  this  was  the  small  intestine,  sigmoid,  or  transverse 
colon.  Nevertheless  the  child  recovered,  and  seven  months  later, 
'^when  the  finger  was  introduced  into  the  artificial  anus,"  a  resisting 
body  was  felt  in  the  pelvis,  which  he  supposed  to  be  the  distended 
rectum.  The  perineal  incision  was  reopened,  and  he  found  that  the 
distended  rectal  pouch  had  since  the  operation  descended  low  enough 
into  the  pelvis  to  be  brought  down  and  sutured  at  the  site  of  the  normal 
anus.  This  case  is  quoted  in  illustration,  first,  of  the  wisdom  of  early 
incision  into  the  peritoneal  cavity;  second,  of  the  difficulty  which  may 
arise  in  inguinal  colotomy  in  children;  third,  as  illustrative  of  the  fact 
that  the  rectal  pouch  may  continue  to  grow  and  descend,  and  eventually 
reach  a  position  from  which  it  may  be  attached  to  the  normal  anus 
long  after  birth.  In  Kronlein's  case  the  inguinal  anus  closed  in  three 
weeks  after  the  rectal  pouch  was  attached  to  the  anus. 

Treatment  of  the  Anal  Cul-de-sac. — We  come  now  to  consider  the 
management  of  those  cases  in  which  the  anus  is  fully  developed  and 
the  rectum  more  or  less  removed  or  has  descended  alongside  of  the 
anal  cul-de-sac,  as  illustrated  in  Fig.  41. 

In  these  cases  the  external  sphincters  are  normal  and  the  anal  cul- 
de-sac,  for  the  space  of  1  to  1|  centimeter  (f  to  f  of  an  inch),  is  per- 


80  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

fectly  formed.  The  treatment  of  this  cul-de-sac  and  the  question  of 
union  between  it  and  the  rectum  (when  the  latter  has  been  found)  has 
created  considerable  discussion.  The  operation  of  end-to-end  union 
between  the  two  culs-de-sac  is  a  very  difficult  one  to  perform,  and  most 
uncertain  in  its  results.  Eecent  surgical  opinion  and  the  results  of 
operations  upon  this  class  of  cases  have  convinced  me  that  it  is  best 
to  dissect  away  the  lining  membrane  of  the  anal  cuJ-de-sac  and  bring 
the  rectal  mucous  membrane  down  to  the  margin  of  the  skin  thus 
freshened  and  suture  it  there.  The  incision  in  such  cases  would  depend 
upon  whether  the  rectal  pouch  can  be  made  out  without  dissection  or 
not.  In  case  this  was  possible,  the  incision  through  the  anus  should 
undoubtedly  be  made  in  the  direction  in  which  the  rectal  pouch  is 
felt;  but  if  the  position  of  the  rectal  pouch  can  not  be  made  out  with- 
out dissection,  then  it  should  be  made  from  the  posterior  margin  of  the 
anal  cul-de-sac  back  to  the  cocc3'x,  just  as  in  the  previous  operations. 

Matas,  in  a  case  in  which  the  rectal  pouch  descended  in  front  of 
the  anal  cul-de-sac,  sutured  the  end  of  the  rectal  pouch  to  the  perineal 
margin,  left  in  situ  the  anal  cul-de-sac  and  incised  the  sfeptum  between 
the  two.  He  says:  "The  objection  to  lateral  ano-proctorrhaphv  (as  we 
might  distinguish  the  suture  of  the  bowel  to  the  rudimentary  anus  as 
practised  in  my  case)  is,  that  it  leaves  a  larger  anal  orifice  than  is 
required,  and  that  the  interposition  of  new  mucosa  in  the  posterior 
segment  will  act  as  a  wedge  and  will  interfere  with  the  perfect  grasp 
of  the  sphincters."  He  therefore  advises  as  a  better  procedure  the 
total  excision  of  the  anal  cul-de-sac,  leaving  the  marginal  anal  mucosa 
intact,  and  suturing  to  this  the  mucous  membrane  of  the  rectal  pouch. 
Aside  from  the  difficulty  of  end-to-end  suture  of  the  rectal  and  anal 
pouches  (the  circumference  of  the  rectal  pouch  being  always  much 
greater  than  that  of  the  anal)  there  will  be  imperfect  coaptation  and 
danger  of  valvular  stricture  eventuall}^  succeeding. 

Colotomy  in  Cases  of  Imperforate  Anus. — Thus  far  we  have  only 
referred  to  the  operation  of  colotomy  as  a  last  resort  in  cases  where 
the  rectum  could  not  be  found,  or  where  it  was  impossible,  owing  to 
other  complications,  to  establish  the  anus  at  its  normal  position.  The 
operation,  however,  merits  a  closer  consideration.  Some  surgeons  hold 
that  an  inguinal  anus  should  be  made  as  a  preliminary  operation  to 
perineal  search  for  the  undescended  rectum  in  all  cases  in  which  the 
latter  can  not  positively  be  felt  through  the  anal  cul-de-sac  or  perinfeum. 
They  hold  that  it  is  more  certain  and  less  fatal  than  proctoplasty,  and 
that  it  does  not  interfere  with  the  ultimate  establishment  of  the  anus 
at  its  proper  site  after  the  child  has  grown  stronger.  The  arguments 
in  favor  of  such  a  procedure  are  not  without  weight.  The  rapidity  with 
which  such  an  operation  can  be  performed  is  urged  in  its  favor,  and 


MALFORMATIONS  OP  THE  ANUS  AND  RECTUM  81 

can  not  be  ignored.  The  fact  that  the  sigmoid  flexure  is  sometimes 
diflicult  to  find  in  children,  or  that  it  generally  rests  upon  the  right 
side  instead  of  the  left  in  early  infancy,  does  not  militate  against  it. 
To  one  familiar  with  these  conditions  it  is  not  difficult,  if  the  abdomen 
is  open,  to  sweep  the  finger  clear  across  the  pelvis  in  these  little  ones 
and  find  the  loop  of  intestine  in  which  it  is  desirable  to  make  the  arti- 
ficial anus.  Again,  it  is  urged  that  in  this  operation  an  opportunity 
will  be  afforded  to  search  the  sacral  curvature  and  deeper  pelvis,  and 
thus  accurately  determine  the  absence  or  jiresence  and  the  location 
of  the  undescended  rectum.  Moreover,  it  is  clauned  that  the  amount 
of  traumatism  and  mutilation  of  the  tissues  necessary  to  perineal  search 
for  the  rectal  pouch  will  be  greatly  lessened  by  a  preliminary  colot- 
omy,  and  that  if,  after  the  abdomen  is  opened,  the  operator  discovers 
the  rectal  pouch  within  easy  reach  of  the  perin^eum,  the  abdominal 
wound  can  be  promptly  closed  and  the  perineal  operation  performed 
with  much  greater  certainty,  and  with  smaller  incisions  than  where 
it  is  attempted  ah  initio.  Furthermore,  the  advocates  of  preliminary 
colotomy  claim  that  after  the  artificial  inguinal  anus  is  established 
and  the  patient  has  recovered  from  the  same,  it  will  be  quite  feasible 
to  pass  a  blunt  probe  or  sound  through  the  lower  segment  of  the  gut 
into  the  rectal  cul-de-sac  and  thus  determine  the  exact  location  of 
this  pouch.  With  the  probe  in  this  position  one  can  dissect  down 
upon  it  with ,  comparative  ease  and  establish  the  anus  in  its  normal 
position  at  a  time  when  the  child  is  well  able  to  withstand  surgical 
interference.  These  advantages  are  undeniable^  and  should  be  given 
due  consideration. 

The  arguments  against  such  an  operation  have  been  based  chiefly 
upon  the  danger  of  invading  the  peritoneal  cavity,  and  the  high  mor- 
tality which  has  followed  the  operation.  Since  Lawson  Tait  has  prac- 
tically dissipated  the  fear  of  invading  this  cavity,  and  since  it  has  been 
shown  that  under  proper  aseptic  precautions  and  with  due  celerity  the 
peritoneal  cavity  of  a  child  can  be  opened  almost  as  safely  as  in  those 
of  greater  years,  this  argument  has  lost  much  of  its  weight.  I^o  one 
would  controvert  the  proposition  that  if  the  fffical  exit  could  be  es- 
tablished at  the  normal  site  without  invading  the  peritoneal  cavity, 
or  subjecting  the  child  to  too  great  and  protracted  surgical  procedures, 
such  a  method  would  be  preferable  to  ingaiinal  colotomy.  But  when 
the  child  is  extremely  weak,  when  immediate  relief  is  urgently  de- 
manded, and  when  the  condition  will  not  justify  even  the  delay  of  a 
prolonged  search  for  the  rectal  pouch,  inguinal  colotomy  undoubtedly 
has  its  advantages. 

Another  argument  against  the  performance  of  this  operation  in 
children  is  based  upon  the  thin  and  fragile  texture  of  the  intestine 
6 


82  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

during  infancy.  It  has  been  lield,  and  justly  so,  that  its  tissues  will 
not  bear  suturing  well,  that  they  are  not  strong  enough  to  hold  the 
gut  firmly  in  the  abdominal  wound,  and  therefore  there  is  great  danger 
of  their  breaking  loose  and  allowing  the  loop  of  the  intestine  to  drop 
back  into  the  abdominal  cavity  after  it  has  once  been  opened,  thus 
infecting  the  peritoneum  and  producing  a  fatal  termination. 

If  it  was  necessary  to  depend  upon  sutures  to  hold  the  gut  in  posi- 
tion, these  facts  would  be  sufficient  to  condemn  the  operation,  except 
as  a  dernier  ressort.  But  this  argument  loses  its  force  when  we  consider 
the  fact  that  the  best  operators  no  longer  use  sutures  to  support  the 
intestine  in  colotomy.  Maydl  and  Eeclus  have  established  the  fact  that 
few  if  any  sutures  are  necessary  in  the  performance  of  this  operation, 
and  that  a  glass  rod  passed  through  the  mesentery  from  one  side  to  the 
other  of  the  wound  forms  a  safer,  a  more  permanent,  and  better  support 
to  the  intestine  than  any  number  of  stitches  can  possibly  do.  Hun- 
dreds of  operations  done  after  this  manner  with  perfect  success  have 
confirmed  their  opinions  that  the  dangers  of  infection,  tearing  loose, 
and  puncture  from  stitches  and  stitch-hole  abscesses  have  been  entirely 
obliterated  by  their  method.  Not  only  is  this  true,  but  the  time  of  the 
operation  has  been  greatly  shortened  and  the  dangers  of  surgical  shock 
proportionately  decreased.  Thus,  where  circumstances  seem  to  demand 
it,  an  inguinal  colotomy  may  be  safely  and  quickly  made  in  children 
with  imperforate  ani,  and  by  it  valuable  lives  may  be  saved  which  would 
almost  certainly  be  lost  if  any  other  method  were  adopted.  The  ques- 
tion of  closure  of  the  artificial  inguinal  anus  will  be  discussed  later  on; 
but  it  may  be  stated  here  that  in  children  such  apertures  will  generally 
close  spontaneously  if  a  normal  exit  for  the  intestinal  contents  has  been 
well  established. 

The  choice  of  operations,  therefore,  between  the  perineal  dissection 
in  search  of  the  rectal  pouch  and  inguinal  colotomy  will  depend  first 
upon  the  knowledge  which  we  have  of  the  proximity  of  this  pouch  and 
the  child's  ability  to  withstand  surgical  operation.  Where  there  is  no 
evidence  that  the  rectal  pouch  can  be  easily  reached,  and  where  the 
child  is  in  an  enfeebled  condition,  with  distended  abdomen,  faecal  vomit- 
ing, and  nausea  in  progress,  one  should  not  hesitate  to  choose  the 
abdominal  route,  perform  an  inguinal  colotomy  at  once,  and  thus  afford 
an  immediate  exit  to  the  intestinal  contents,  and  an  escape  for  the  gases 
which  are  causing  the  distention  and  the  constitutional  disturbances. 

Proctoplasty  Versus  Colotomy. — The  term  proctoplasty  has  been 
adopted  by  recent  writers  to  describe  the  various  perineal  methods  for 
operations  upon  imperforate  ani.  There  has  been  a  long  and  animated 
discussion  concerning  the  comparative  mortality  from  proctoplasty  and 
colotomy  in  these  cases.     Able  and  vigorous  writers  have  been  engaged 


MALFORMATIONS   OF   THE  AXUS  AND  RECTUM 


83 


upon  either  side.  Eecently  the  wage  of  battle  seems  to  favor  the 
perineal  method. 

In  the  total  number  of  operations  done,  there  is  no  doubt  that  the 
percentage  of  fatalities  is  less  in  proctoplasty  than  in  colotomy.  It 
must  not  be  forgotten,  however,  that  a  large  number  of  the  cases  done 
by  the  former  method  have  been  of  the  simplest  t}'pe,  and  have  required 
operations  of  no  magnitude.  In  many  of  these  cases  the  rectal  pouch 
has  been  in  apposition  with,  or  very  close  to,  the  perinseum,  so  that 
it  could  be  reached  by  a  very  shallow  incision  and  without  involving 
any  important  organs.  The  list  of  these  operations  also  includes  many 
cases  of  malformation,  such  as  atresia  ani  vaginalis,  which  would  not 
have  proved  fatal  had  nothing  been  done  for  them.  On  the  other 
hand,  the  cases  in  which  primary  colotomy  has  been  performed  have 
been  those  of  the  most  desperate  character,  many  of  them  having 
already  undergone  prolonged  perineal  search  previous  to  the  colotomy 
operation. 

In  studying  the  comparative  figures,  therefore,  we  must  not  attach 
too  great  importance  to  the  percentage  column.  In  the  old  statistics 
the  operation  of  puncture  by  the  trocar  was  always  included,  and  a 
very  high  mortality  resulted.  Thus,  Anders  gives  for  it  50  per  cent, 
Curling  76.4  per  cent,  and  Cripps  82.3  per  cent.  This  operation  is 
now  practically  abandoned,  and  need  not  be  considered  here. 

The  following  brief  table  represents  the  comparative  results  of 
colotomy  and  proctoplasty  in  the  collections  of  cases  by  Anders,  Curl- 
ing, and  Cripps: 

Mortality  from  Different  Operations  for  Imperforate  Anus 


Anders. 


Curling. 


Cripps 


Author. 


Colotomy,  primary..    52.3  per  et. 

Colotomy,  secondary 
— i.  e.,  after  proc- 
toplasty had  been 
attempted  . 

Proctoplasty . 

Proctoplasty,  omit-! 
ting  atresia  ani 
vaginalis 38.2  per  ct. 

Total  cases 67 


47.6  per  ct. 


.4  per  ct. 


30.5  per  ct. 


39.3  per  ct. 


100 


32.7  per  ct. 
40.4  per  ct. 


43.7  per  ct.  (32  cases). 
4o.2  per  ct.  (42  cases). 


39.3  per  ct.  (66  cases). 
140 


From  the  table  one  will  see  at  a  glance  that  the  perineal  method 
is  less  fatal  than  colotomy.  We  must  not  forget,  however,  the  varia- 
tions in  gravity  between  the  class  of  cases  in  which  the  one  and  the 
other  operation  is  adopted. 

In  a  study  of  the  modern  journal  literature  upon  this  subject,  140 
cases  in  which  operations  have  been  done  for  malformations  of  the 
rectum  have  been  collected.    Of  these,  66  cases  were  performed  by  the 


84         THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

perineal  and  sacral  route  with  20  deaths,  a  mortality  of  39.3  per  cent. 
In  43  cases  colotomy  was  done  secondary  to  perineal  and  sacral  opera- 
tions with  19  deaths,  a  mortality  of  45.3  per  cent.  Thirty-two  primary 
colotomies  were  done  with  14  deaths,  a  mortality  of  43.7  per  cent.  The 
introduction  of  these  tables  would  consume  too  much  space.  But  almost 
without  exception  primary  colotomy  was  done  in  the  most  grave  condi- 
tions. This  is  emphasized  by  the  fact  that  the  mortality  in  immediate 
colotomies  is  very  slightly  less  than  in  those  which  were  done  secondary 
to  extensive  perineal  operations.  These  facts  are  borne  out  by  those  of 
Matas  (Transactions  of  the  American  Surgical  Association,  1897).  The 
high  mortality  given  by  Anders  for  colotomy  in  these  cases  is  explained 
by  the  fact  that  in  21  operations  done,  13  of  the  patients  had  previously 
been  subjected  to  prolonged  perineal  operations,  and  thus  their  condition 
was  not  what  it  should  have  been  in  order  to  begin  the  colotomy.  More- 
over, the  low  mortality  in  his  table  for  proctoplasty  in  general  is  made  up 
from  a  number  of  exceedingl}'^  simple  cases  in  which  there  were  only 
membranous  divisions  between  the  rectum  and  anus,  and  others  of  atre- 
sia ani  vaginalis.  If  these  cases  are  left  out  of  his  tables  the  mortality 
from  colotomies  will  be  largely  decreased,  and  that  from  proctoplasty 
will  be  considerably  increased.  But,  after  all  allowances  are  made,  proc- 
toplasty, or  the  perineal  operation,  still  has  the  advantage  in  a  smaller 
mortality.  Nevertheless,  it  is  the  condition  of  the  child  and  the  urgency 
of  the  case,  and  not  the  statistical  mortality  which  should  determine  us  to 
choose  proctoplasty  or  colotomy  in  any  individual  instance.  In  ex- 
hausted children  with  tympanites  and  symptoms  of  intestinal  sepsis,  the 
most  expeditious  methods  of  relief  are  demanded,  and,  as  Matas  well 
says:  "  Under  such  adverse  conditions  it  can  not  be  denied  that  inguinal 
colotomy  is  the  quickest  and  safest  operation." 

Treatment  of  Ahnormal  Narronnng  of  the  Anus. — In  cases  of  abnor- 
mal narrowing  of  the  anus  no  operative  procedure  is  called  for  in  the 
early  period  of  life,  provided  a  reasonable  exit  exists  for  the  fluid  con- 
tents of  the  bowel.  Gradual  and  gentle  dilatation  with  bougies,  or 
with  an  ordinary  uterine  dilator,  will  generally  bring  the  parts  up  to  a 
comparatively  normal  size.  This  conservative  method  of  treatment  will 
afford  the  necessary  exit  for  faecal  matter,  and  in  this  condition  the 
child  may  wait  until  it  has  developed  sufficient  strength  to  stand  surgi- 
cal procedures.  If  the  contraction  should  prove  to  be  of  a  fibrous 
nature,  which  condition  is  exceedingly  rare,  posterior  proctotomy,  or, 
which  is  better  still,  the  excision  of  the  fibrous  tube,  bringing  down  of 
the  mucous  membrane  and  suturing  it  to  the  skin  may  be  performed  at 
a  later  date  (Lannelongue,  Bull,  et  mem.  soc.  de  chir.  de  Paris,  1884, 
p.  300;  Degouy's  Theses,  Lyons,  1894;  Couty,  Theses,  Paris,  1889;  and 
Vauelaire,  Med.  infant,  Paris,  1895,  p.  86). 


MALFORMATIONS  OF  THE  ANUS  AND  EECTUM  85 

Treatment  of  Palatial  Occlusions. — When  the  obstruction  consists  of 
a  fold  or  band  of  skin  running  from  the  scrotum  or  posterior  commis- 
sure of  the  vulva  back  to  the  coccyx,  there  is  no  advantage  in  delay 
even  though  there  be  a  moderate  exit  for  the  meconium.  Such  a  band 
can  be  snipped  off  at  its  ends  with  scissors  and  dissected  away.  The 
anus  shoiild  then  be  periodically  dilated  until  it  assumes  its  normal 
shape  and  size.  When,  however,  this  partial  occlusion  occurs  at  a 
higher  level,  and  the  exit  for  the  meconium  is  very  limited,  the  ques- 
tion as  to  management  is  somewhat  more  difficult. 

Matas  {of.  cit.)  states  that  simple  incision  of  these  crescentic 
diaphragms  has  not  been  satisfactory.  The  procedure,  he  says,  is  fol- 
lowed by  recurring  strictures  and  consequent  obstruction  to  the  fsecal 
passages.  He  therefore  advises  the  total  excision  of  the  membranes 
and  suturing  the  edges  of  the  wound  together.  Most  authors,  however, 
do  not  appear  to  have  seen  any  such  results  from  simple  incision  in 
these  cases.  In  fact  they  state  that  if  such  membranous  obstructions 
are  thoroughly  incised,  they  will  atrophy  and  entirely  disappear.  The 
author's  experience  has  been  limited  to  4  cases  of  this  kind,  and  he 
has  not  been  able  to  follow  them  to  any  late  period  of  life;  but  two 
of  them  he  has  seen  at  the  ages  of  four  and  six  years  respectively, 
and  no  such  strictures  had  occurred.  He  is  of  the  opinion  that  Matas's 
views  are  largely  theoretical  upon  this  point,  and  that  inasmuch  as  the 
simple  incision  is  almost  entirely  without  danger  and  involves  no  shock 
it  ought  to  be  employed  in  all  these  cases.  If  a  stricture  should  occur, 
it  may  be  resected  later  on  in  life.  The  possibility  of  hsemorrhage  in 
incising  these  obstructions  should  always  be  borne  in  mind.  One  case 
has  been  reported  in  which  the  child  died  from  this  cause. 

Treatment  of  Complete  Occlusion  dy  a  Membrane  or  Diaphragm. — 
These  cases  are  among  the  simplest  as  well  as  the  rarest  of  rectal  mal- 
formations. Usually  this  membrane  is  so  thin  and  diaphanous  that 
the  color  of  the  meconium  is  transmitted  through  it,  the  bulging  of 
the  rectal  pouch  is  easily  felt  when  the  child  cries  or  when  pressure 
is  made  on  the  abdomen,  and  there  is  little  doubt  about  the  close  prox- 
imity of  the  pouch. 

Sometimes  these  membranes  are  so  thin  and  fragile  that  even 
examination  with  the  finger,  especially  if  the  nail  be  sharp,  will  rup- 
ture them,  and  there  will  be  a  spurt  of  meconium  from  the  anus.  At 
other  times,  however,  the  membranes  are  more  dense  and  fibrous,  and 
while  the  impulse  can  be  felt,  ordinary  pressure  fails  to  rupture  them. 
The  impression  to  the  touch  in  such  cases  is  very  similar  to  that  pro- 
duced by  the  bag  of  waters  in  the  early  stages  of  labor.  In  such  simple 
cases  a  crucial  incision  through  the  membrane,  carried  from  one  side 
to  the  other  of  the  anus,  will  be  all  that  is  necessary.     The  little  tri- 


86  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

angular  folds  left  b}'  such  incision  atrophy  and  disappear,  and  no 
remains  of  them  can  be  seen  in  after  life. 

Unfortunately,  however,  there  is  sometimes  more  than  one  such 
membrane.  "When  this  is  the  case  the  fluid  which  escapes  through  the 
first  incision  is  only  a  thick  serum  or  mucus  and  not  meconium.  Great 
care  must  be  exercised  in  determining  the  nature  of  this  fluid,  else 
in  these  cases  the  operation  will  be  of  no  avail.  The  finger  should  be 
introduced  well  up  into  the  rectal  pouch  after  the  incision  is  made, 
the  parts  well  dilated,  and  the  operator  should  assure  himself  that  no 
secondary  membrane  exists  at  a  higher  level.  Voillemier's  case,  in  which 
there  were  three  such  distinct  membranes,  forcibly  illustrates  the 
necessity  of  such  precaution.  One  point  must  be  taken  into  considera- 
tion in  these  cases,  and  that  is  that  the  impulse  imparted  to  the  finger 
may  be  due  to  fluid  in  the  peritoneal  cavity.  Incisions  through  such 
membranes  should  be  made  with  the  greatest  aseptic  precautions  in 
order  to  prevent  any  disastrous  results  following.  When  a  second  mem- 
brane is  found  to  exist,  a  tubular  speculum  should  be  inserted  and  the 
parts  carefully  observed  to  see  that  the  cavity  from  which  the  first 
fluid  escapes  is  lined  with  mucous  membrane  and  is  entirely  shut  off 
from  the  peritoneal  cavity.  Through  this  speculum,  under  aseptic  pre- 
cautions, a  long  aspirating  needle  may  be  introduced  through  the  second 
membrane  if  fluctuation  and  impulse  can  be  felt.  If  meconium  is 
dra-mi  through  this  needle,  then,  with  the  needle  still  in  position,  an 
incision  may  be  made  through  the  second  membrane  and  the  wound 
gently  dilated. 

At  these  higher  levels  wide  crucial  incisions  are  to  be  avoided,  as 
they  may  accidentally  involve  the  peritoneal  cavity.  The  making  of  an 
exit  sufficient  for  functional  purposes  is  as  much  as  can  be  safely  under- 
taken in  such  cases,  and  if,  at  a  later  period,  the  lateral  folds  thus  left 
produce  any  obstruction  or  inconvenience  they  may  be  excised  by 
scissors  or  Pennington  clips. 

Treatment  of  Cases  in  ichich  the  liectnm  opens  at  some  Abnormal 
Position  on  the  Shin. — Interference  in  such  cases  is  not  generally 
urgently  demanded,  especially  if  the  opening  be  in  the  perineal,  sacral, 
vulvar,  or  abdominal  regions.  The  exit  is  generally  sufficient  for 
functional  purposes  during  early  life,  and  the  time  at  which  operative 
interference  is  undertaken  can  be  selected  with  reference  to  the  con- 
venience of  the  family  and  the  condition  of  the  child.  Happily  in 
these  cases  there  is  no  necessity  for  prolonged,  blind  dissection  in  search 
of  the  missing  gut. 

The  abnormal  opening,  if  it  be  not  too  far  removed  from  the  natural 
anus,  should  be  dissected  out,  together  with  the  rectal  pouch,  and 
sutured  to  the  skin  at  the  site  of  the  normal  anus.     ^Tiere  the  abnormal 


MALFORMATIONS  OF  THE  AXUS  AND  RECTUM        87 

opening  is  too  far  remoYed  from  the  perinseum  to  be  brought  down  and 
sutured  in  this  position,  the  rectum  should  be  searched  for  by  perineal 
dissection,  and  if  found  should  be  brought  down  and  its  mucous  mem- 
brane sutured  to  the  skin  at  the  site  of  the  anus.  The  fsecal  current 
will  thus  be  turned  in  the  natural  direction.  The  abnormal  openings 
will  gradualh'  atrophy  and  close  under  such  circumstances.  If  they 
do  not,  however,  at  a  second  sitting  they  may  be  dissected  out,  invagi- 
nated,  and  closed  by  Lembert  sutures. 

Where  the  abnormal  opening  is  connected  with  the  rectum  by  a 
long  fistulous  tract,  as  in  those  eases  where  it  opens  at  the  prepuce, 
the  lower  end  of  the  scrotum,  or  in  the  gians  penis,  obstruction  will 
be  likely  to  occur.  Such  cases  demand  an  early  interference.  The 
obliteration  of  these  long  mucus-lined  tracts,  without  a  too  elaborate 
dissection,  is  a  question  of  considerable  difficulty.  The  author's  opinion 
is,  although  he  has  had  no  experience  in  such  cases,  that  the  opening 
into  the  rectal  pouch  at  the  normal  site  of  the  anus  should  be  estab- 
lished just  as  soon  as  the  child's  condition  will  permit.  "When  this 
has  been  done,  the  tract  leading  to  the  abnormal  opening  should  be 
cut  across  at  a  point  close  to  its  entrance  into  the  rectal  pouch,  and  a 
ligature  should  be  applied  to  the  proximal  end.  This  end  should  then 
be  invaginated  into  the  rectum  and  retained  there  with  Lembert  sutures. 
The  cut  end  of  the  remaining  portion  of  the  tract  should  be  closed  in 
the  same  manner  and  left  to  atrophy  after  it  has  been  thoroughly 
cleansed.  It  is  a  well-known  fact  that  mucous  tracts  thus  abandoned, 
so  far  as  functional  activity  is  concerned,  do  atrophy  and  become  noth- 
ing more  than  fibrous  cords  which  are  not  detrimental  to  the  individual. 

Where  the  abnormally  placed  anus  is  at  some  such  remote  position, 
as  on  the  abdomen,  the  chest,  the  shoulder,  or  in  the  neck,  the  ingenuity 
of  the  operator  will  be  put  to  the  severest  test  to  devise  some  means  of 
establishing  a  convenient  outlet  for  the  fsecal  material.  It  is  improba- 
ble in  such  cases  that  the  rectal  pouch  is  or  can  be  brought  near  to 
the  perinasum.  If  a  loop  of  the  sigmoid  or  colon  can  be  brought  down 
and  sutured  at  the  anal  site  it  will  probably  serve  all  necessary  pur- 
poses. Otherwise  an  artificial  anus  should  be  made  in  the  left  inguinal 
region  after  the  manner  of  Witzel  or  Bailey.  Certainly  no  interfer- 
ence beyond  dilating  the  abnormal  opening  to  facilitate  the  escape  of 
the  intestinal  contents  should  be  undertaken  in  such  a  case  until  the 
child  has  arrived  at  an  age  to  justify  a  prolonged  and  difficult  surgical 
operation. 

Treatment  of  Cases  in  wMcli  the  Eednni  opens  into  Some  OtJier 
Viscus. — This  class  of  cases  embraces  about  40  per  cent  of  all  cases 
of  malformation  of  the  rectum,  and  the  large  majority  of  them  are 
those  in  which  the  rectum  opens  at  some  point  in  the  vagina  or  vulva. 


88  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

The  Rectum  comnmnicntcs  icith  Bladder. — Where  the  rectum  opens 
into  the  bladder  it  is  a  question  of  immediate  operation  or  death  in  a 
short  time  from  infection. 

The  size  of  the  opening  into  the  bladder  has  little  to  do  with  the 
prognosis.  The  freer  the  discharge  of  the  intestinal  contents  into  the 
bladder  the  more  rapid  will  be  the  progress  of  infection.  The  prog- 
nosis in  this  condition  is  always  unfavorable,  and  yet  operation  offers 
the  only  hope  of  life. 

All  teachings  with  regard  to  such  malformations  are  largely  theo- 
retical. Some  few  cases  have  been  operated  upon,  but  scarcely  two  by 
the  same  method.  Martin  (Diet,  des  Scs.  med.,  vol.  xxiv,  p.  137)  sug- 
gested as  a  means  of  relief  in  these  cases  that  a  perineal  anus  should 
be  established  and  the  recto-vesical  sseptum  incised  down  to  the  neck 
of  the  bladder,  thus  furnishing  a  free  exit  for  the  combined  contents 
of  the  two  organs.  This  appears  to  be  a  very  blind  operation,  and  its 
eventual  benefit  to  the  child  would  be  of  a  most  doubtful  character. 

From  a  rational  point  of  view  there  are  two  methods  of  procedure 
in  such  cases,  both  of  which  involve  abdominal  section.  The  author 
believes  such  cases  should  be  operated  upon  at  the  earliest  possible 
moment  by  a  full,  free  incision  into  the  abdominal  cavity.  After  this 
the  condition  of  the  parts  and  the  location  of  the  opening  into  the 
bladder  will  determine  the  future  steps  of  operation.  Where  the  com- 
munication is  high  up  and  can  be  reached,  it  is  perfectly  feasible  to 
separate  the  two  organs  at  the  point  of  communication,  invaginate  the 
openings  into  each,  and  suture  them,  provided  there  is  an  external  ori- 
fice for  the  escape  of  the  fsecal  matter  from  the  rectum.  If,  however, 
there  is  an  imperforate  anus  this  condition  should  be  remedied  first 
by  proctoplasty  or  colotomy. 

Where  the  opening  into  the  bladder  is  low  down,  in  the  neighbor- 
hood of  the  trigone,  and  beyond  the  reach  of  the  operator  to  suture 
with  any  degree  of  certainty,  it  will  be  better  to  make  a  permanent 
inguinal  anus,  and  close  up  the  lower  end  of  the  colon  entirely.  There 
is  little  danger  in  such  cases  that  the  urine  will  escape  upward  into 
the  gut,  and  if  the  fscal  current  is  shut  off  from  the  bladder  the  distal 
end  of  the  divided  intestine  will  atrophy,  and  eventually  the  communi- 
cation will  close. 

The  fact  that  this  operation  condemns  the  child  to  an  artificial 
anus  all  its  life  must  be  considered  by  the  parents  and  surgeon.  These 
artificial  ani  are  no  longer  the  nightmare  which  they  were  in  former 
days.  Even  in  adults  they  are  so  made  at  the  present  day  as  to  possess 
almost  absolute  control,  and  in  a  position  in  which  they  are  compara- 
tively convenient.  Xow,  when  such  an  arrangement  is  made  in  infancy, 
the  child  is  taught  from  birth  to  utilize  it,  and  it  becomes  just  as  con- 


MALFORMATIONS  OF  THE   ANUS  AND  RECTUM  89 

venient  as  if  it  vreve  in  its  normal  position.  Such,  an  anus  made  in  child- 
hood develops,  eyentually  almost  as  perfect  spliincteric  control  as  lias 
the  normal  anus.  Certainh'  there  is  no  question  of  choice  betAveen  the 
two  procedures,  if  it  is  possible  to  carry  out  the  first  with  any  degree 
of  safety;  but  where  the  opening  is  so  low  down  that  one  can  not  reach 
and  safely  suture  it,  colotomy  is  the  more  conserYative  operation,  and 
offers  a  better  prognosis. 

The  Rectum  communicates  with  the  Urethra. — ^In  this  type  of  cases  the 
dangers  of  infection  are  less  than  in  the  preceding  varieti,-,  and  while 
the  escape  of  meconium  is  limited  the  condition  is  generally  not  an 
urgent  one.  The  conditions  for  surgical  interference  are  also  much 
more  favorable,  the  bowel  is  always  lower  down  and  nearer  the  pelvic 
floor,  and  the  point  at  which  the  rectum  opens  into  the  urethra  can 
be  made  out  by  touch  or  by  the  use  of  a  fine  j^robe.  VTlien  it  is  in  the 
membranous  or  bulbous  portion  it  will  be  easy  to  dissect  down  upon 
the  rectal  pouch,  disconnect  it  from  the  urethra,  and  bring  the  fresh- 
ened edges  of  the  orifice  by  which  it  emptied  into  the  urethra  back 
to  the  normal  position  of  the  anus  after  enlarging  it  to  whatever  extent 
is  necessary  to  produce  a  good  aperture.  "When  the  opening  is  near 
the  meatus  the  case  should  be  treated  as  advised  for  preputial  cases. 

The  time  at  which  this  operation  should  be  done  depends  largely 
upon  the  condition  of  the  child.  "WTien  there  is  a  free  escape  of 
meconiimi  and  no  distention  of  the  abdomen,  the  operation  may  be 
deferred  until  the  child's  strength  justifies  surgical  interference.  If, 
however,  the  escape  of  the  meconium  is  obstructed,  the  abdomen 
swollen,  the  child  fretful  and  peevish,  the  operation  should  be  done 
at  once. 

As  to  what  becomes  of  the  opening  in  the  urethra  after  such  an 
operation  as  this,  one  has  only  to  consult  his  experiences  with  perineal 
section  for  strictures  and  fistula  in  adult  life.  If  the  urethra  is  split 
and  the  redundant  mucous  membrane  cut  away,  these  fistulous  tracts 
close  spontaneously  and  without  difficulty.  So  also  in  the  child.  After 
the  rectum  is  detacihed  from  its  connection  vrith  the  urethra  a  simple 
perineal  fistula  is  left,  which  eventually  heals  of  its  own  accord.  The 
prognosis  in  such  cases  is  comparatively  good. 

The  Bectum  opens  into  the  Vagina. — In  these  cases  the  opening  may 
occur  at  any  point  from  the  margin  of  the  vulva  up  to  the  junction 
of  the  vagina  with  the  uterine  cervix;  it  is  generally  free  enough  to 
allow  the  passage  of  meconium,  and  even  solid  matter,  without  great 
difficulty;  it  may  be  comparatively  large,  and  yet  the  discharge  of 
meconium  be  obstructed  by  an  imperforate  hymen.  In  such  cases  the 
diagnosis  is  made  from  the  bulging,  greenish  membranes  between  the 
vulvge,  and  incision  of  the  h}-men  should  be  the  first  step  in  treatment. 


90  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

If  the  opening  between  the  vagina  and  the  rectum  is  not  sufficiently 
free  it  should  be  dilated  by  bougies  or  a  uterine  dilator.  Further 
interference  should  be  governed  by  the  condition  of  the  child. 

At  what  age  should  the  operation  for  vaginal  anus  be  under- 
taken? In  the  author's  experience,  children  at  the  age  of  three  to 
five  years  stand  surgical  operations  very  well.  He  has  operated  upon 
a  large  number  of  children  at  this  age  for  various  conditions  of  the 
rectum  and  anus,  and  has  never  j^et  seen  one  suffer  particularh^  from 
surgical  shock  or  haemorrhage.  From  this  and  some  experience  with 
the  malformation  under  consideration,  it  would  appear  wise  to  select 
this  period  of  life  for  its  correction.  If,  however,  the  condition  is  dis- 
covered in  infancy,  and  the  aperture  is  too  small  to  admit  of  the 
functional  activity  of  the  intestine,  one  may  be  called  upon  to  decide 
whether  it  is  not  better  to  operate  then  than  to  dilate  the  opening  and 
wait  until  later  years.  The  author  has  no  hesitancy  in  saying  dilate 
it  and  wait.  In  general  the  opening  will  be  found  sufficient  for  func- 
tional purposes,  and  the  time  most  suitable  and  convenient  may  be 
elected  for  operative  interference.  Many  methods  have  been  devised 
for  carrying  out  this  procedure.  One  of  the  first  operations  consisted 
in  making  an  incision  through  the  perineum  and  anus  up  to  the  ab- 
normal opening  in  the  vagina,  thus  giving  an  exit  to  the  fa?cal  matter 
through  the  perinaeum  at  the  site  of  the  normal  anus.  A  tube  or  cannula 
is  passed  into  the  rectum  and  kept  there  until  the  anterior  portion  of 
the  wound  has  healed.  Such  operations  are  far  from  successful.  Later 
on  the  operation  was  modified  by  making  this  same  incision,  cutting 
and  dissecting  the  mucous  membrane  from  around  the  margin  of  the 
abnormal  opening,  and  suturing  the  anterior  edges  of  the  gut  together 
from  this  point  down  to  the  level  of  the  perina?um;  the  mucous  mem- 
brane of  the  gut  was  then  sutured  to  the  skin  at  the  site  of  the  normal 
anus,  and  the  perina-um  and  vagina  were  closed  by  deep  sutures  as  in 
the  ordinary  operations  for  complete  rupture  of  the  perinaeum.  Such 
operations  were  fairly  successful,  but  it  was  a  long  time  before  the 
patient  obtained  any  sphincteric  control  over  the  movements  of  the 
bowel. 

Another  operation  consisted  in  dissecting  upward  in  the  perineum 
until  the  rectal  pouch  was  found;  the  mucous  membrane  of  this  pouch 
was  then  sutured  to  the  skin  at  the  margin  of  the  anus,  thus  leaving 
two  exits  to  the  rectum,  one  in  the  vagina  and  one  in  the  anus.  The 
operators  trusted  that,  owing  to  disuse,  the  opening  in  the  vagina 
would  close  spontaneously.  Such  hopes,  however,  were  fallacious. 
Later  on  they  were  led  to  attempt  to  close  the  abnormal  openings  by 
cauterizing  them,  which  procedure  led  to  a  number  of  successes,  but 
was  not  altogether  satisfactory.     Especially  was  this  operation  unsuc- 


MALFORMATIONS  OF  THE  ANUS  AND  EECTUM  91 

cessful  in  cases  in  which  the  condition  had  been  allowed  to  reach  adult 
life,  oAving  to  the  fact  that  the  sphincter  muscles  having  never  been 
brought  into  action  had  atrophied  and  practically  disappeared,  conse- 
quently the  patients  upon  whom  the  operation  was  done  suffered  from 
persistent  incontinence  of  fa?cal  matter.  After  this  the  problem  of 
correcting  the  malformation  was  practically  solved  b}^  Eizzoli  (Gross's 
System  of  Surgery,  vol.  ii,  p.  205,  sixth  edition),  who  says  that  inas- 
much as  these  vaginal  ani  always  possess  a  certain  amount  of  voluntary 
control  there  must  exist  around  them  a  sphincter  muscle,  and  that 
the  preservation  of  such  an  organism  would  be  of  the  utmost  impor- 
tance to  the  child.  His  method  of  accomj^lishing  this  is  as  follows: 
An  incision  is  made  from  the  posterior  margin  of  the  vagina  backward 
to  the  point  at  -which  the  normal  anus  should  end;  the  perineal  tissues 
are  carefully  dissected  to  reach  the  rectal  pouch;  this  is  then  carefully 
loosened  from  its  attachment  all  around,  and  the  vaginal  anus  is  dis- 
sected out  intact,  dragged  down  to  the  position  of  the  normal  anus, 
and  carefully  transplanted  there.  The  perineal  tissues  in  front  of  the 
gut  are  then  brought  together  by  buried  catgut  or  deep  silver  sutures, 
and  the  mucous  membrane  of  the  vagina  is  carefully  sutured,  thus  restor- 
ing completely  the  recto-vaginal  sseptum,  and  closing  all  communication 
between  the  two  organs.  By  this  procedure  the  natural  opening  in 
the  intestine  is  perfectly  preserved  with  all  its  sphincteric  power,  and 
the  danger  from  non-union  or  retraction  of  the  parts  is  practically 
obliterated.  It  also  has  the  great  advantage  of  restoring  the  perineum 
and  recto-vaginal  saeptum,  a  matter  of  the  utmost  importance  to  the 
woman.  Another  advantage  in  this  operation  is  that  it  practically 
obliterates  any  diverticulum  in  the  rectum  at  the  point  of  communica- 
tion with  the  vagina,  such  as  is  very  likely  to  occur  in  oj^erations  by 
other  methods;  and,  again,  it  obviates  the  necessity  of  repeated  opera- 
tions such  as  were  necessary  in  the  cases  of  Aveling  (Lancet,  December 
20,  1884),  and  Buckmaster  (Trans.  Amer.  Gjn^ec.  Ass'n,  1894,  vol.  xix, 
p.  275).  Cases  sometimes  occur  in  which  this  operation  is  not  feasible, 
owing  to  the  fact  that  there  are  two  or  more  openings  into  the  vagina, 
as  has  been  reported  by  Ainsworth  (Bodenhamer,  op.  cit.,  p.  227).  In 
such  instances  much  ingenuity  must  be  exercised  in  performing  a  plastic 
operation  which  will  cover  the  necessities  of  the  case.  If  two  openings 
are  close  together  they  mav  be  converted  into  one  by  a  simple  incision, 
the  margins  of  which  may  be  puckered  with  a  purse-string  suture  and 
attached  by  the  mucous  membrane  to  the  margin  of  the  skin  at  the 
site  of  the  normal  anus.  Wlien,  however,  these  openings  are  separated 
by  some  considerable  space,  it  would  be  better  to  dissect  out  the  lower 
opening,  completely  detach  the  rectum  from  all  its  attachments  up  to 
the  upper  opening,  and  close  this  by  inversion  and  the  Lembert  sutures. 


92  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

The  lower  abnormal  anus  should  then  be  transplanted  to  the  position 
of  the  normal  anus. 

The  Rectum  communicates  with  the  Uterus. — Such  cases  are  practically 
so  rare  that  one  can  scarcely  speak  with  any  definiteness  concerning 
their  treatment.  As  stated  before,  the  author  knows  of  but  one  case, 
and  no  operation  was  performed  to  remedy  it.  It  seems,  however, 
that  the  proper  proceeding  in  such  cases  would  be  to  establish  an  anus 
at  the  normal  site,  if  possible,  and  to  follow  this  by  laparotomy,  division 
of  the  canal  connecting  the  two  organs,  and  inversion  and  suture  of 
the  apertures  in  each,  after  the  same  manner  as  has  been  advised  in 
those  cases  in  which  the  rectum  communicates  with  the  bladder.  If, 
however,  the  rectal  cul-de-sac  ends  at  its  communication  with  the  uterus, 
the  establishment  of  the  anus  at  the  normal  position  would  be  practi- 
cally impossible.  The  only  recourse  left  to  us  under  such  circum- 
stances would  be  the  establishment  of  an  inguinal  anus  and  the  closure 
of  the  lower  end  of  the  gut.  If,  however,  upon  opening  the  abdomen 
for  this  procedure  the  sigmoid  flexure  and  rectal  pouch  are  found 
sufficiently  long  to  reach  the  perineal  floor,  one  might  dissect  the 
rectum  from  its  attachment  to  the  uterus,  close  the  opening  in  that 
organ,  and  finally  bring  the  opening  into  the  intestine  down  and  suture 
its  mucous  membrane  to  the  skin  at  the  site  of  the  normal  anus.  Such 
a  proceeding,  however,  has  never  been  attempted,  as  far  as  can  be 
learned,  and  the  above  remarks  are  simply  suggestive. 

The  Bectum  and  Anus  are  Normal,  hut  have  opening  into  them  the 
Ureters,  the  Uterus,  or  Vagina. — Some  20  cases  of  such  malforma- 
tions have  been  described  by  various  authors.  Bodenhamer  has  col- 
lected 7  in  which  the  ureters  terminated  in  the  rectum,  and  9  in 
which  the  vagina  or  uterus  ended  in  this  organ.  In  those  cases  in 
which  the  ureters  terminated  in  the  rectum  the  bladder  was  foimd 
absent,  and  the  rectum  performed  all  the  functions  of  both  organs. 
Any  operation  intended  to  remedy  such  a  deformity  would  be  irrational, 
inasmuch  as  there  would  be  no  reservoir  into  which  to  transplant  the 
ureters.  The  dangers  of  infection  traveling  from  the  rectum  up  the 
ureters  and  into  the  kidney  will  always  exist;  although  Nature  seems 
able  to  protect  herself  in  such  cases,  and  persons  with  these  abnormali- 
ties have  lived  to  a  comparatively  good  age  without  suffering  from 
such  complications. 

In  those  cases  in  which  the  uterus  or  vagina  opens  into  the  rectum, 
operative  interference  may  be  safely  undertaken  if  a  proper  period 
and  state  of  the  patient  be  selected.  Unfortunately  the  victims  of  this 
malformation  rarely  realize  their  condition,  and  cases  have  been  known 
to  grow  to  womanhood,  marry,  and  bear  children  successfully,  even 
although  afflicted  with  this  deformity. 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM       93 

Ball  says:  "  It  does  not  appear  that  there  would  be  greater  difficulty 
in  operating  upon  these  cases  than  in  those  of  a  converse  condition 
already  described,,  where  the  rectum  opens  into  the  vagina."  This 
might  be  so  or  not,  from  the  fact  that  where  the  vagina  or  the  uterus 
opens  into  the  rectum  the  communication  is  not  by  a  small,  narrow 
opening,  such  as  is  the  case  in  the  inverse  condition,  but  by  a  large 
patulous  communication  which  it  would  require  an  extensive  ojDeration 
to  close.  Only  one  operation,  so  far  as  I  am  aware,  has  been  under- 
taken for  this  condition,  and  that  was  successful  (Bodenhamer). 


CHAPTEE   III 
EXAMINATION  AND  DIAGNOSIS 

The  importance  of  local  examinations  in  diseases  of  the  anus  and 
rectum  can  not  be  overestimated.  Here  more  than  in  any  other  por- 
tion of  the  body  are  the  diseases  liable  to  progress  rapidly,  and  care- 
lessness and  errors  in  diagnosis  often  allow  the  simplest  affection  to 
assume  great  magnitude.  In  constitutional  and  self-limited  diseases 
delay  of  a  day  or  two  in  making  the  diagnosis  seldom  results  in  any 
injury  to  the  patient;  but  in  progressive  diseases,  such  as  those  gener- 
ally found  in  the  rectum,  a  delay  of  even  a  day  may  be  followed  by  the 
most  disastrous  results,  to  say  nothing  of  the  discomfort  and  suffering 
which  the  patient  is  unnecessarily  forced  to  bear.  The  author  has  re- 
ported elsewhere  (Transactions  Georgia  State  Medical  Association,  1899) 
a  case  of  ordinary  thrombotic  hfemorrhoids  in  which  the  family  physician 
failed  to  recognize  the  condition.  After  two  or  three  days  the  throm- 
bus became  infected,  and  an  abscess  developed  which  burst  into  the 
rectum,  thus  constituting  a  blind  internal  fistula,  necessitating  an  opera- 
tion and  more  than  two  months  of  convalescence.  In  the  abscess  was 
a  broken-down  clot,  showing  clearly  that  the  trouble  had  originated  in 
a  simple  thrombotic  hgemorrhoid.  Under  proper  diagnosis  and  man- 
agement, this  patient  would  have  been  cured  in  three  or  four  days, 
and  he  would  have  been  spared  not  only  the  loss  of  much  time  and  a 
great  deal  of  suffering,  but  also  an  actual  danger  to  his  life  from  sepsis. 
In  the  large  majority  of  rectal  diseases  an  early  diagnosis  and  proper 
treatment  will  result  in  a  rapid  cure,  and  in  malignant  diseases  of  the 
rectum  it  is  only  in  the  early  stages  that  there  is  hope  to  eradicate 
them.  In  such  cases,  therefore,  positive  and  immediate  diagnosis  upon 
the  first  appearance  of  the  symptoms  is  of  paramount  importance. 

The  subjective  symptoms  in  rectal  diseases  are  always  referable  to 
more  than  one  pathological  cause.  They  are  of  great  value,  but  no 
diagnosis  should  ever  be  made  of  any  rectal  condition  until  the  patients 
have  been  thoroughly  examined,  both  by  digital  and  instrumental  meth- 
ods. The  embarrassment  of  the  patient  and  the  disagreeable  task  for 
the  doctor  will  never  be  an  excuse  for  the  omission  of  such  examina- 
94 


EXAMINATION  AND  DIAGNOSIS  95 

tions.  Diagnosis  of  rectal  diseases  in  their  early  stages  is  sometimes 
very  difficult,  inasmuch  as  the  subjective  symptoms  are  often  referred 
elsewhere.  Such  reflex  symptoms  should  be  known  and  appreciated  by 
every  physician,  and  should  emphasize  the  necessity  of  local  examination. 
The  methods  employed  in  the  examination  and  diagnosis  of  rectal  dis- 
eases may  be  classified  as  historical,  digital,  and  instrumental. 

Historical  Examination. — When  the  patient  consults  the  doctor  for 
any  form  of  disease,  whether  rectal  or  otherwise,  a  careful  review  of 
his  family  and  personal  history  is  imperative.  It  is  sometimes  tedious 
and  monotonous  to  listen  to  a  patient  tell  his  own  story  in  his  own  way, 
and  often  much  that  is  irrelevant  is  introduced;  but  after  all  it  has  its 
advantages.  It  calms  his  nervous  sensibilities  and  makes  him  feel  at 
home  with  the  physician,  to  whom  he  is,  perhaps,  a  stranger.  There 
is  nothing  so  conducive  to  confidence  in  a  patient  as  the  impression 
that  his  physician  is  patiently  and  thoroughly  interested  in  his  case. 
Therefore,  when  such  patients  enter  the  consulting-room,  a  history  of 
their  personal  and  family  life  should  be  patiently  heard.  Heredity  may 
or  may  not  have  any  great  influence  in  diseases  of  the  rectum,  but 
many  patients  have  a  very  positive  impression  that  it  does,  and  to  these 
the  fact  that  the  doctor  is  looking  into  it  is  very  consoling.  A  man's 
occupation,  his  environments  and  his  habits  may  or  may  not  have  any- 
thing to  do  with  the  symptoms  from  which  he  is  suffering;  but  it  is 
very  important  in  advising  individuals  as  to  regimen  that  one  should 
be  sure  they  are  not  already  following  this  very  course,  even  to  excess. 
As  an  example  of  this,  the  author  had  a  patient  consult  him  some  years 
ago  who  was  much  displeased  with  a  consultation  which  he  had  had 
only  a  few  hours  previously.  The  cause  of  his  discontent  was  that 
the  doctor  had  told  him  he  needed  more  physical  and  outdoor  exer- 
cise. The  young  man  was  an  atlilete  who  had  gone  stale  from  over- 
training, and  was  well  aware  of  the  fact  that  any  increase  of  exercise 
had  persistently  made  him  feel  worse.  A  man's  environments  may  not 
have  anything  to  do  with  his  disease,  and  yet  when  one  is  unacquainted 
with  these,  he  may  sometimes  carelessly  attribute  symptoms  to  them 
or  give  advice  concerning  them  that  make  him  appear  ridiculous.  A 
calm  hearing,  therefore,  of  the  patient's  history  will  be  advantageous 
in  more  ways  than  one.  After  this  has  all  been  told,  one  may  begin 
a  direct  examination  with  regard  to  the  symptoms  which  have  been 
detailed.  The  method  of  the  physician's  examination  often  impresses 
a  patient  favorably  or  unfavorably,  and  has  much  to  do  with  gaining 
or  losing  his  confidence.  If  our  inquiries  are  at  random  and  our  ques- 
tions are  ambiguous,  and  if  we  omit  to  inquire  into  what  the  patient 
considers  his  important  symptoms,  he  is  very  likely  to  suppose  that 
we  know  little  about  them.     Whereas,  if  our  inquiries  are  concise,  direct, 


96  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

and  to  the  point  with  regard  to  the  symptoms  of  which  he  complains, 
and  if  we  by  a  knowledge  of  reflex  effects  call  his  attention  to  symp- 
toms which  he  has  inadvertently  observed,  or  which  he  has  neglected 
to  observe,  he  will  at  once  be  convinced  that  the  examiner  knows  what 
he  is  talking  about,  and  will  submit  with  confidence  to  his  directions. 
In  recording  the  history  of  a  patient,  his  name,  age,  home  address,  voca- 
tion, and  domestic  station  should  all  be  noted.  His  family  history  should 
be  briefly  but  carefully  put  down.  His  personal  history  from  infancy 
ought  to  be  inquired  into,  and  all  the  material  facts  with  regard  to  early 
habits  and  diseases  should  be  elicited  as  far  as  possible.  These  early 
habits  and  diseases  often  have  a  material  bearing  upon  rectal  diseases. 
Many  patients  are  aware  of  the  fact  that  they  have  been  constipated  from 
infancy,  and  some  will  detail  indistinct  recollections  of  rectal  diseases 
in  early  life.  The  knowledge  of  these  facts  is  of  the  utmost  importance 
to  the  examiner.  After  such  general  facts  have  been  taken  cognizance 
of,  the  direct  and  local  examination  of  the  patient  should  be  taken  up. 
The  symptoms  suggesting  local  examination  of  the  rectum  may  be  enu- 
merated as  follows: 

First,  indigestion,  flatulence,  loss  of  appetite,  irregularity  of  the 
bowels,  or  constipation. 

Second,  vague  aching  pains  about  the  pelvis  or  sacral  region  and 
shooting  down  the  left  leg. 

Third,  a  sense  of  constriction  or  weight  about  the  pelvis.  This  is 
especially  important  in  males. 

Fourth,  spasmodic  or  periodical  dysuria,  without  adequate  cause,  in 
the  genito-urinary  apparatus. 

Fifth,  a  tendency  to  diarrhoea,  especially  in  the  morning. 

Sixth,  the  presence  of  mucus,  pus,  shreds,  or  blood  in  the  fffical 
discharges. 

Seventh,  irregular  menstruation  or  dysmenorrhoea  in  young  women. 

Eighth,  restlessness  at  night,  picking  the  nose,  scratching  of  the 
abdomen  or  anus,  and  vitiated  appetite  in  young  children. 

All  or  most  of  these  symptoms  may  arise  from  diseases  of  the  rec- 
tum, and  at  the  same  time  many  of  them  may  be  due  to  other  affections. 
The  fact  that  they  are  very  frequently  due  to  rectal  disorders  renders 
a  local  examination  imperative.  These  facts  should  be  known  to  the 
family  practitioner  more  thoroughly  even  than  to  the  rectal  specialist, 
for  he  is  the  one  first  consulted  in  regard  to  these  conditions,  and  it  is 
nearly  alw^ays  through  his  advice  that  the  rectal  surgeon  is  consulted.  The 
patient  generally  knows  there  is  something  wrong  with  his  rectum  when 
he  consults  the  specialist,  and  therefore  these  reflex  symptoms  are  not 
of  so  much  importance  in  his  examination  as  in  that  of  the  family 
practitioner.     The  latter  should  be  prepared  to  examine  the  rectum 


EXAMINATION  AND  DIAGNOSIS  97 

quite  as  well  as  the  chesty  and  he  should  not  hesitate  to  do  so  in  any 
case  presenting  symptoms  referable  to  it.  When  through  delicacy  and 
bashfulness  the  patient  refuses  to  allow  such  an  examination,  the  physi- 
cian should  equally  as  firmly  refuse  to  prescribe  for  the  symptoms. 
After  the  general  facts  and  history  have  been  recorded,  and  their  bear- 
ings duly  weighed,  one  should  then  inquire  into  the  existing  conditions, 
as  follows: 

State  of  the  Bowels. — One  should  examine  as  to  the  habitual  state 
of  the  bowels:  whether  it  is  normal,  constipated,  or  diarrhoeal.  If  the 
patient  is  constipated,  to  what  extent  does  this  condition  exist.  Is 
there  a  stool  every  day,  or  does  it  only  occur  when  laxatives  have  been 
taken?  When  the  stool  does  occur,  is  the  faecal  material  soft,  con- 
sistent, and  of  normal  shape,  or  is  it  small,  tape-like,  or  hard  and  in 
little  balls?  It  is  important  to  know  when  the  stool  has  been  passed 
whether  it  is  of  sufficient  quantity  and  clean,  or  covered  with  mucus 
and  tinged  with  blood.  If  the  condition  of  the  bowels  is  diarrhoeal, 
one  should  inquire  whether  the  passages  are  watery  or  semifluid, 
whether  large  quantities  are  passed  and  painlessly,  or  whether  the 
passages  are  scanty,  mucous,  and  attended  with  pain,  tenesmus,  and 
subsequent  exhaustion. 

Pain. — If  the  patient  gives  a  history  of  pain,  one  should  inquire  as 
to  the  exact  point  at  which  it  is  felt;  whether  at  the  anus,  within  the 
rectum,  in  the  sacral  region,  about  the  pelvis,  in  the  inguinal  region, 
or,  as  often  happens,  in  the  uterus,  neck  of  the  bladder,  or  urethra.  It 
is  also  important  to  know  whether  it  extends  to  other  regions.  Pain 
shooting  down  the  leg,  for  instance,  has  been  described  by  Hilton  as 
constantly  associated  with  rectal  disease.  The  time  at  which  the  jjain 
occurs  should  also  be  inquired  into;  whether  it  is  before  or  after  stools, 
and  how  long  it  lasts;  whether  it  is  persistent,  occurs  with  every  stool, 
or  only  occasionally.  Again,  one  ought  to  know  the  nature  of  this  pain; 
whether  it  is  acute,  cutting,  burning,  or  of  a  dull  aching  character.  All 
of  these  symptoms  are  of  material  importance,  for  they  point  with  more 
or  less  accuracy  to  the  proper  diagnosis  of  the  case. 

Itching  and  Spasm  of  the  Sphincter. — Patients,  when  asked  about 
pain  in  the  rectum,  often  say  they  have  no  real  pain,  but  rather  dis- 
comfort, uneasiness,  and  itching,  or  sometimes  a  spasm  of  the  anus. 
The  time  and  circumstances  of  such  symptoms  should  be  carefully 
noted. 

Protrusion. — The  patient  should  be  asked  if  he  suffers  from  any 
unusual  protrusion  about  the  anus;  if  so,  we  sliould  inquire  as  to  when 
it  occurs  and  how  it  is  brought  about;  whether  by  straining  or  upon 
slight  exertion.  One  should  also  know  whether  it  disappears  spon- 
taneously or  if  it  is  necessary  to  restore  the  parts  to  their  normal  posi- 
7 


98,  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

lion;  if  so,  is  the  restoration  diflficiilt  or  easy.  It  is  necessary  also  to 
know  whether  such  protrusions  are  hard  or  soft,  smooth  and  regular, 
or  localized  and  nodular.  One  should  furthermore  inquire  if  the 
patient  can  produce  the  protrusion  at  will,  or  whether  it  only  appears 
when  he  goes  to  stool.  He  should  also  know  whether  there  is  any  pain 
produced  hy  handling  the  protrusion.  If  it  is  present  at  the  time  of 
examination,  one  should  examine  carefully  the  vngse,  whether  they  are 
circular  or  run  up  and  down,  and  he  shovdd  also  observe  any  abrasion, 
ulceration,  or  other  abnormalities  upon  the  parts. 

Ilahils. — The  habits  and  liistory  of  the  patient  should  be  most  care- 
fully inquired  into.  Is  he  accustomed  to  the  use  of  enemas?  Is  he 
in  the  habit  of  sitting  long  at  the  shrine  of  Cloacus  with  his  pipe  and 
paper  as  companions?  Is  there  an  unsatisfied  feeling  of  something 
more  to  come  away  when  the  bowels  have  moved?  Is  he  the  victim 
of  pederasty?  Has  he  a  history  of  venereal  disease?  Has  he  an  heredi- 
tary tendency  to  tuberculosis  or  to  malignant  growths? 

All  these  points  should  be  carefully  noted,  and  by  the  time  one 
has  obtained  a  satisfactory  account  of  them,  he  will  generally  have 
information  such  as  will  aid  and  direct  him  materially  in  the  local 
examination. 

Freparaiion  of  the  Patient  for  Examination. — In  order  to  make  a 
proper  and  careful  examination  of  the  rectum,  all  constricting  clothing 
should  be  removed  or  loosened:  corsets,  tight  waistbands,  or  anything 
which  has  a  tendency  to  crowd  the  small  intestines  down  into  the 
pelvis,  or  prevent  their  rising  upward  toward  the  diaphragm,  should 
be  removed.  The  rectum  should  always  be  empty  in  order  to  make 
a  final  and  satisfactory  examination  of  this  organ;  but  sometimes,  where 
an  imperfect  or  unsatisfactory  history  of  the  habitual  state  of  the 
bowels  has  been  obtained,  it  is  better  to  examine  the  patient  as  to  this 
condition  first,  then  move  the  bowels  with  an  enema,  and  proceed  with 
the  complete  examination  later  on.  The  author  has  time  and  again 
had  patients  come  to  him  who  had  previously  taken  enemata,  and  yet 
found  their  rectums  fidl  of  hard,  inspissated  fa?cal  material.  ^\Tiether 
this  material  had  come  down  into  the  rectum  after  the  movement  of 
the  bowel,  or  whether  the  injection  had  failed  to  remove  it,  it  was 
impossible  to  say.  As  a  rule,  therefore,  if  it  is  practicable,  the  first 
examination  of  a  patient's  rectum  should  be  made  before  an  enema 
is  given.  By  such  an  examination,  if  pus,  blood,  mucus,  or  inspissated 
faecal  material  are  present,  they  can  be  seen;  whereas,  if  an  injection 
has  been  taken  and  the  rectum  tlioroughly  cleaned  out  before  tlie 
physician  examines  it,  these  substances  may  be  entirely  removed,  and 
the  condition  causing  them  may  be  overlooked.  It  requires  a  little 
more  time  to  make  the  double  examination  in  this  way,  but  in  the 


EXAMIXATION  AND   DIAGNOSIS 


author's  experience  it  has  been  more  satisfactory.  If  upon  the  pre- 
liminary examination  the  rectum  is  found  full  of  ffecal  matter^  or  sub- 
stances interfering  ^rith  a  thorough  diagnosis,  an  enema  should  be 
given  and  the  patient  allo-^'ed  to  retire  until  these  have  been  passed. 
Where  the  physician's  office  is  not  so  arranged  that  the  toilet-room  is 
adjoining  it,  he  should  always  have  at  hand  a  conmiode,  so  that  in 
case  of  an  emergency  after  giving  the  enema  the  patient  may  relieve 
himself  at  once  'n-ithout  the  danger  of  an 
accident  in  passing  from  one  room  or  floor 
to  another  in  order  to  reach  the  toilet.  The 
cut  here  given  (Fig.  49)  illustrates  a  very- 
practical  and  efficient  commode  for  the  physi- 
cian's office.  It  is  so  arranged  that  there  is 
very  little  escape  of  isecal  odor  from  it,  and 
at  the  same  time  one  would  hardly  suspect 
that  it  was  anything  but  an  ordinary  stool. 
For  the  specialist's  office  certain  double  fau- 
cets and  stopcocks  have  been  arranged  by 
which  a  patient  can  be  given  an  enema  or 
irrigated  directly  from  the  water-pipe.  Such 
an  arrangement  is  described  by  Dr.  Kelsey 
as  follows: 

It  consists  '^  of  a  glass  jar  holding  one 
gallon^  which  stands  upon  a  shelf  7  feet  above 
the  floor,  and  is  filled  by  a  rubber  tube  con- 
nectiag  with  what  is  popularly  known  as  a 

barbers'  faucet,  by  which  either  hot  or  cold  water  can  be  draAvn  from 
the  same  tube  at  pleasure."  The  apparatus  may  also  be  used  for  irri- 
gating the  rectum,  the  temperature  being  regulated  b}-  a  thermometer 
in  the  jar,  and  the  flow  may  be  kept  up  indefinitely. 

This  is  an  excellent  arrangement,  but  the  jar  should  not  be  set 
more  than  3  feet  above  the  level  of  the  patient,  for  too  great  force  is 
objectionable  for  either  irrigation  or  enemata.  It  is  not  indispensable, 
however.  The  ordinary  fountain  syringe  serves  every  purpose  for  giv- 
ing rectal  enemata.  It  can  be  sterilized,  and  the  tips,  at  least,  should  be, 
after  each  use  of  them.  The  question  of  what  sort  of  a  tip  is  best  for 
giving  a  rectal  enema  will  be  often  asked  of  a  physician.  A  hard-rubber 
tip  with  an  olive-shaped  end,  smooth,  polished,  and  well  lubricated,  or  a 
medium-sized  soft-rubber  catheter,  are  the  only  instruments  with  which 
a  patient  ought  ever  to  administer  an  enema  to  himself.  "When  the  phy- 
sician or  a  trained  nurse  is  called  upon  to  give  the  enema,  the  tip  de- 
scribed, or  a  small-sized  TTales  bougie,  are  the  instruments  of  choice. 
The  ordinary  Davidson  bulb  syringe  is  preferable  to  the  fountain  syringe 


Fig.  49. — Coiriiocz  eob 
Office  Use. 


100 


THE  ANUS,   RECTUM,  AND  PELVIC  COLON 


when  the  injection  is  given  tlirongli  a  long  tuhe  like  the  Wales  bougie, 
inasmuch  as  the  impulse  lifts  up  the  folds  of  mucous  membrane  from 
in  front  of  the  bougie  and  facilitates  the  passage  of  the  instrument  up- 
ward into  the  sigmoid  flexure. 

Immediately  after  the  enema  has  passed,  the  patient  should  be  laid 
upon  a  lounge  or  table  before  any  protrusions  or  prolapse,  which  may 
have  occurred  during  the  action  of  the  bowel,  have  disappeared.  Some- 
times it  is  well  to  feel  or  examine  the  parts  before  the  patient  leaves 


Fig.  50. — Left  Lateral  or  Sims's  Posture. 
The  bed  of  the  louuge  being  raised  so  as  to  form  a  table. 

the  commode,  as  motion,  especially  walking  or  climbing  up  on  a  table, 
may  cause  their  retraction,  and  the  opportunity  of  viewing  them  will 
be  thus  lost.  In  order  to  avoid  this^  it  is  well  to  instruct  the  patient 
before  he  retires  to  the  toilet-room  or  seats  himself  upon  the  commode, 
that  he  shall  not  replace  any  prolapse,  and  shall  simply  use  a  little 
moist  cotton  or  gauze  in  cleansing  himself.  One  should  always  have 
present  in  his  office,  if  possible,  a  trained  female  nurse  or  an  attendant 
to  wait  upon  ladies  and  prepare  them  for  examination,  to  adjust  their 
clothing,  and  assist  in  the  administration  of  enemata.  She  should 
not  be  present,  however,  during  the  questioning  of  the  patient,  as  this 
part  of  the  examination  should  be  confidential.  All  unnecessary  exposure 
of  the  patient's  person  should  be  avoided;  ladies  should  be  properly 
postured  and  covered  with  a  sheet  by  the  nurse  before  the  examination 


EXAMIXATIOX  AXD   DIAGNOSIS 


101 


is  begun,  and  in  case  of  male  patients  this  should  be  done  by  the  surgeon 
before  the  nurse  is  called  in. 

Position  for  Examination. — There  are  four  jDositions  in  ^hich  a 
patient  may  be  examined  for  diseases  of  the  rectum,  and  each  of  them 
has  its  special  use.  The  first  and  most  generally  useful  is  the  left 
lateral,  so-called  Sims's  position  (Fig.  50).  This  is  obtained  by  laying 
the  patient  upon  the  left  side,  the  chest  upon  the  table,  with  the  left 
arm  behind  the  back,  the  thighs  well  flexed  upon  the  body,  and  the 
hips  elevated  upon  a  hard  pillow.  In  the  large  majority  of  cases  this 
position  is  sufficient  for  all  examinations,  whether  digital,  ocular,  by 
specula,  or  through  the  sigTuoidoscope.  In  ver}-  stout  people,  howeyer, 
the  rectum  is  so  retracted  and  covered  in  by  the  large  folds  of  the  but- 
tock that  it  is  difficult  to  obtain  a  good  view  of  the  parts  in  this  posi- 
tion, and  almost  impossible  to  introduce  an  ordinary  speculum  with 
satisfaction.     In  such  cases  other  positions  are  found  more  satisfactory. 

Exaggerated  Lithotomy  Position  (Fig.  51). — This  position  is  ordinarily 
the  most  convenient  for  operations  upon  the  rectum,  and  it  also  has 


Fig.  51. — Exaggerated  Lithotomt  Position,     (Bryant.) 


its  field  of  usefulness  in  examination.  The  author  has  several  times 
attempted  to  introduce  the  sigmoidoscope  in  the  Sims's  and  also  in 
the  knee-chest  posture  without  avail,  and  has  succeeded  with  com- 
parative ease  after  having  placed  the  patient  in  the  lithotomy  posi- 
tion.     In    stout    patients   this   position    afEords    an   excellent    view    of 


Fig.  52. — Ixcobrect  Knee-chest  Posture. 


Fig.  53. — Correct  Knee-chest  rosTUBE. 


102 


EXAMINATION  AND  DIAGNOSIS 


103 


the  anus,  and  in  females  it  enables  iis  at  the  same  time  to  examine 
the  condition  of  the  uterine  organs  and  determine  their  intiuence  upon 
the  rectal  symptoms.  Every  ph3'Sician's  office  is  furnished  with  some 
table,  chair,  or  device  by  which  such  a  position  can  be  easily  obtained. 
Tlie  Knee-cliest  Posture  (Figs.  53,  53). — This  is  obtained  in  several 
ways.     Where  the  patient  is  strong  and  able  to  retain  himself  in  posi- 


FiG.  54. — Patient  held  en*  Z^^:E-CHEST  Posti.-ee  by  Straps  and  B.iNDS  (Kelly). 


tion  for  some  time,  or  where  the  examination  is  to  be  very  brief,  he 
may  be  placed  upon  a  table  resting  upon  his  knees,  the  shoulders  or 
chest  lying  upon  the  same  level  as  the  knees,  the  body  well  flexed 


104 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


upon  the  thighs.  In  this  position  the  weight  of  the  abdominal  or- 
gans is  taken  entirely  off  the  rectum,  and  the  dilating  effect  of  atmos- 
pheric pressure  can  be  easily  obtained.  It  is  almost  impossible  to  main- 
tain this  posture  under  anajsthesia  without  a  specially  prepared  ap- 
paratus for  holding  the  patient,  such  as  that  employed  by  Dr.  Howard 
Kelly  (Fig.  54).  Such  an  apparatus  could,  of  course,  be  used  without 
an  anaesthetic,  but  it  would  be  very  uncomfortable  to  the  patient.  More- 
over, this  position,  although  a  most  useful  one,  is  an  exceedingly  em- 
barrassing one,  especially  to  ladies;  it  is  difficult  to  induce  them  to 

assume  it  in  the  first 
place,  and  very  diffi- 
cult for  them  to  main- 
tain it  in  the  second. 
]\Iartin,  of  Cleveland, 
has  devised  a  compli- 
cated but  exceedingly 
useful  chair  (Fig.  55) 
by  which  the  patient 
can  be  placed  in  this 
position  and  held  there 
for  an  indefinite  period 
without  much  discom- 
fort or  embarrassment. 
The  Squatting  or 
Stool  Posture.  —  This 
position  is  not  gener- 
ally given  as  one  in 
which  to  make  exam- 
inations. The  author 
has  found  it  very  use- 
ful, however,  in  a  number  of  conditions.  A  patient  sometimes  finds 
it  very  difficult  when  lying  upon  the  side,  or  when  in  the  knee-chest 
posture,  to  strain  and  bring  into  sight  protrusions  or  prolapses  which 
habitually  occur  when  at  the  stool;  but  when  in  this  position  he  can 
easily  produce  them.  When  a  patient  is  in  other  positions,  especially 
the  knee-chest  posture,  prolapse  of  the  third  degree  is  likely  to  recede, 
and  the  diagnosis  may  be  impossible;  whereas  in  the  squatting  posture 
such  a  prolapse  is  easily  brought  down  by  the  patient's  straining,  so 
that  it  impinges  upon  the  end  of  the  finger  introduced  into  the  anus, 
and  the  diagnosis  is  easily  made.  The  position  is  also  useful  in  cases 
of  stricture  and  tumors  of  the  rectum  which  are  above  the  reach  of  the 
finger.  AHien  they  are  only  removed  a  short  distance  above  the  reach 
of  the  index  finger,  if  the  patient  is  placed  in  this  position  and  caused 


Fig.  55. — Patient  in  Knee-chest  Posture  on  Martin 
Chair. 


EXAMINATION  AND  DIAGNOSIS 


105 


to  bear  down,  they  may  frequently  be  brought  within  reach,  and  thus 
information  may  be  elicited  which  could  not  be  otherwise  obtained 
except  by  the  administration  of  an  anesthetic. 

Apparatus. — There  is  great  difference  of  opinion  among  the  medical 
men  and  specialists  as  to  the  advantages  of  lounges,  chairs,  or  tables 
for  the  examination  of  patients.  Ordinarily  a  good  gynaecological  table 
will  serve  every  purpose.  A  lounge  is  generally  too  low  for  examina- 
tions, but  it  is  sometimes  of  the  greatest  convenience  in  the  doctor's 
office.  Chairs  also  have  advantages,  in  that  the  patient  is  seated  thereon 
and  by  special  mechanism  placed  in  any  position  desired  by  the  operator. 
The  author  uses  a  lounge  devised  by  the  late  Dr.  Little  (Fig.  56).    The 


Fig.  56. — The  Little  Office-lounge  closed. 


bed  of  the  lounge  is  5  feet  long  and  2^  feet  wide,  and  its  mechanism 
is  simple.  When  it  is  lifted  up  it  forms  a  table  3-|  feet  high  (Fig.  50), 
and  is  abundantly  large  for  any  operation  or  position  which  may  be  re- 
quired in  a  physician's  oflEice. 

Eecently,  however,  in  order  to  obtain  the  advantages  of  the  knee- 
chest  posture,  and  to  maintain  it  without  inconvenience  and  exhaustion 
to  a  patient,  the  ingenious  chair  of  Martin  has  been  used.  This  chair  is 
a  modification  of  the  well-known  Yale  gynecological  chair,  which  by 
a  crank  places  the  patient  from  a  Sims's  position  into  a  perfect  knee- 
chest  posture  without  his  moving  or  being  inconvenienced.  A  patient 
is  seated  in  the  upright  position,  his  right  leg  crossed  over  the  left,  and 
the  left  arm  rests  upon  the  back  of  the  chair.  The  pillow  is  held  with 
the  right  arm  underneath  the  head,  and  the  chair  is  thrown  back- 


106  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

ward  into  a  horizontal  position.  The  retaining  shoulder-strap  is  placed 
over  the  right  arm  and  attached  to  the  snap  which  holds  it.  With  the 
lever  in  the  right  hand,  the  crank  which  controls  the  screw  is  then 
rapidly  revolved  and  the  patient  is  turned  slowly  and  gradually  into 
the  posture  indicated  in  the  cut.  The  head  of  the  patient  rests  upon 
a  device  which  is  arranged  so  as  to  support  it,  and  in  this  way  every 
advantage  of  the  knee-chest  posture  is  obtained.  For  specialists  in 
rectal  diseases  this  chair  is  of  great  assistance,  and  for  one  who  is  in 
the  habit  of  using  a  chair  for  gynaecological  and  other  work,  the  com- 
bination in  no  wise  detracts  from  its  ordinary  usages.  Pennington,  of 
Chicago,  has  devised  a  table  in  which  Martin's  principle  is  carried  out. 
It  is  light  and  can  be  easily  transported  from  place  to  place.  All  such 
appliances  are  convenient  and  of  assistance,  but  they  are  not  absolutely 
necessary. 

.  In  all  examinations  of  the  rectum  it  is  better  to  begin  with  the 
Sinis's  position.  It  is  the  least  embarrassing  to  the  patient,  and  is  gener- 
ally the  only  one  which  will  be  necessary. 

External  Appearances. — Having  placed  the  patient  in  position,  a 
careful  observation  of  all  external  appearances  should  be  made.  The 
shape  of  the  anus  should  be  noted;  whether  it  is  normal,  protruding, 
or  retracted  and  funnel  shaped,  and  whether  the  pigment  about  it  is 
normal,  increased_,  or  reduced.  The  epidermis  should  be  examined 
carefully  for  parasites  and  pediculi,  and  its  condition  noted;  whether 
it  is  normal,  white  and  sodden,  or  red  and  excoriated;  whether  it 
is  moist  or  dry  and  brittle,  smooth  or  nodular  and  swollen  at  points, 
and  whether  there  are  any  scars,  ulcerations,  or  fistulous  o])enings 
about  the  anal  orifice.  Palpation  of  the  parts  is  of  importance,  for  by 
this  are  elicited  any  tense  or  painful  points  that  indicate  abscesses  or 
peri-rectal  inflammation  and  induration.  By  palpation  it  is  possible 
to  follow  up  a  fistulous  tract  through  its  indurated  line,  and  thus  to 
make  a  diagnosis  without  the  use  of  a  probe,  which  is  always  painful 
and  often  unsatisfactory.  If  there  are  any  external  growihs,  such  as 
condylomata,  fibroids,  polypi,  or  connective-tissue  htemorrhoids,  these 
should  be  carefully  examined,  and  their  condition,  whether  painful, 
inflamed,  constricted,  or  thrombotic,  should  be  noted.  Little  thrombi 
about  the  anus  are  very  frequent,  and  sometimes  cause  a  distress  entirely 
out  of  proportion  to  their  appearance.  If  there  is  a  protrusion  present, 
one  should  carefully  observe  all  its  characteristics,  especially  the  direc- 
tion of  the  rugfp,  and  whether  or  not  it  is  excoriated  or  ulcerated. 
Epithelioma  of  the  anus  is  often  apparent  upon  the  external  surfaces, 
and  where  it  is  so  one  may  clip  off  a  small  section  for  microscopic 
examination  without  much  pain  to  the  patient  by  the  application  of 
cocaine  or  orthoform.     Assuming  that  no  such  external  abnormalities 


EXA:.nXATIOX  AXD  DIAGXOSIS  107 

exist,  the  examiner  should  proceed  to  look  higher  up.  'With  the  but- 
tocks pulled  -o-ell  apart  and  the  patient  straining  slightly,  one  can  see 
pretty  well  all  of  the  anal  canal.  If  there  be  a  fissure  or  haemorrhoids 
they  can  generally  be  brought  into  view  by  this  means,  and  polj^Di  low 
down  may  also  be  seen  during  this  part  of  the  examination.  One  should 
be  careful  to  note  the  condition  of  the  muco-cutaneous  border  of  the 
anus,  for  frequently  the  dragging  of  the  buttocks  apart  stretches  this 
membrane,  and  if  it  is  in  an  unhealthy  condition  such  as  the  dry, 
brittle  state  in  which  it  is  foimd  in  atrophic  catarrh  of  the  rectum  and 
in  some  forms  of  syphilis,  it  will  crack  in  numerous  little  points,  some- 
times bleeding,  but  more  often  appearing  like  little  button-holes — ^not 
deep  enough  to  cause  actual  pain,  but  sensitive  to  the  touch  and  to 
irritants.  At  this  point  one  should  observe  the  condition  of  the  radiat- 
ing folds  of  the  anus.  If  one  or  more  of  them  is  inflamed  or  swollen, 
it  would  indicate  some  ulceration  or  irritation  in  that  area  of  the  rectum 
directly  above  it.  If,  however,  they  are  all  congested  and  hypertrophic, 
some  general  inilammation  or  affection  of  the  rectum  will  be  indicated. 
Valvular  constriction  of  the  anus  may  sometimes  be  determined  b}-  such 
an  ocular  examination. 

Digital  Examination. — Having  proceeded  thus  far,  the  physician 
will  have  obtained  whatever  information  is  possible  without  digital  or 
ocular  examination  of  the  rectum  itself.  Here  the  educated  finger 
becomes  our  most  important  agent,  at  least  so  far  as  the  first  four 
inches  of  the  organ  are  concerned.  This  should  be  well  lubricated 
before  any  attempt  to  introduce  it  into  the  rectum.  The  author  has 
tried  many  substances  as  lubricants  for  instruments  and  the  finger  in 
rectal  diseases,  and  has  finally  settled  upon  vaseline  as  the  most  satis- 
factory, except  in  cases  where  some  stimulating  or  cauterizing  substance 
is  to  be  applied.  In  such  cases  one  should  use  some  sort  of  lubricant 
which  can  be  washed  off,  and  which  will  not  interfere  with  the  action 
of  the  drug.  Ordinar}'  non-irritating  or  Castile  soap  is  probably  as 
good  as  any  other  substance  under  such  circumstances,  but  there  are  a 
number  of  vegetable  preparations  upon  the  market  which  serve  this  pur- 
pose very  well.  Such  hibricants  should  be  kept  in  collapsable  tubes. 
The  old  pot  of  oil  or  jar  of  grease  into  which  the  finger  and  instruments 
are  dipped  day  after  day,  infecting  one  patient  from  another,  is  a  relic 
of  medical  barbarism,  and  should  be  discarded  from  every  physician's 
office.  The  vaseline  or  lubricant  in  tubes  can  be  sterilized,  it  is  clean 
and  convenient,  and  the  slight  increase  in  expense  is  inconsiderable. 

In  introducing  the  finger  into  the  rectum,  one  should  remember 
that  the  anus  is  closed  by  a  very  sensitive,  irritable  muscle,  and  that 
any  roughness  or  undue  haste  will  cause  spasm  and  increase  the  diffi- 
culty and  pain  of  an   examination.     It   should  be  introduced  slowly 


108  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

and  with  a  boring  motion,  first  upward  and  forward  toward  the  vagina 
or  prostate  until  the  internal  sphincter  muscle  is  passed,  and  then 
backward  into  the  ampulla  of  the  rectum.  A  mistake  in  directing  the 
finger,  or  roughness  in  its  use,  will  cause  pain  and  spasm  such  as  will 
discourage  the  patient,  and  sometimes  prevent  a  thorough  examination. 
As  the  finger  is  passed  through  the  anus  one  should  study  the  condi- 
tion of  the  sphincter  muscle.  A  twitching,  tender,  spasmodic  sphincter 
indicates  some  acute  disease  near  the  margin;  a  hard,  firm,  resisting 
sphincter  indicates  a  chronic  condition  which  has  caused  hypertrophy 
of  the  muscle;  and  a  relaxed,  flaccid,  lifeless  one  leads  us  to  suspect 
some  exhausting,  malignant,  or  constitutional  disease.  As  the  finger 
passes  beyond  the  margin  of  the  external  sphincter  it  should  be  swept 
around  tlie  anal  canal  to  examine  the  crypts  of  Morgagni  and  the  pil- 
lars of  Glisson,  to  elicit,  if  possible,  the  existence  of  any  ulceration  or 
other  pathological  condition.  Hypertrophied  papillas  may  be  diagnosed 
by  this  procedure.  It  is  just  at  this  point,  between  the  external  and 
internal  sphincter,  that  the  educated  finger  most  often  recognizes  the 
internal  opening  of  a  fistula,  fluctuation  of  perirectal  abscesses,  and  the 
presence  of  small  foreign  bodies  which  have  lodged  in  the  crypts  or 
been  caught  in  the  grasp  of  the  muscles.  The  education  of  the  finger 
to  recognize  abnormalities  in  this  portion  of  the  rectum  is  the  first  and 
most  important  step  in  the  development  of  a  rectal  specialist.  Without 
this  tactile  erudition  one  can  never  make  a  success  in  the  treatment  of 
these  diseases.  There  is  no  one  thing  that  will  give  more  satisfaction 
in  practise  than  the  ability  to  diagnose  the  internal  opening  of  a  fistula 
by  touch.  The  comfort  to  the  patient,  the  certainty  of  the  operator 
when  he  feels  the  opening,  and  the  great  assistance  it  affords  him  in 
operating  upon  tortuous  fistulous  tracts,  render  this  accomplishment 
of  inestimable  value  to  one  who  practises  in  this  line.  An  uneven 
spot,  elevated  or  depressed,  with  an  indurated  base,  and  more  sensitive 
to  touch  than  the  rest  of  the  circumference,  reveals  to  the  experienced 
examiner  more  than  any  probe  can  tell,  and  he  who  has  experienced  it 
a  few  times  recognizes  the  condition  as  unerringly  as  the  skilful  musi- 
cian will  a  string  out  of  tune. 

After  the  examination  of  this  portion  of  the  organ,  the  finger  should 
be  carried  through  the  internal  sphincter  and  swept  gently  around  its 
upper  surface.  The  impression  that  internal  haemorrhoids  can  be  felt 
in  this  way  is  a  mistake.  Unless  there  is  true  hypertrophy  of  the  con- 
nective tissue  one  can  not  feel  them  at  all.  He  may,  however,  recognize 
ulcerations  whether  simple,  tubercular,  or  specific.  As  the  finger  is 
swept  around  the  rectum  the  levator  ani  muscle  can  be  felt  and  its 
condition  determined.  One  can  also  determine  whether  the  mucous 
membrane  is  smooth  and  without  the  normal  folds,  thus  indicating 


EXAMINATIOX  AXD  DIAGNOSIS  109 

atony;  or  whether  it  is  harsh  and  dry,  thus  indicating  atrojDhY  of  its 
glands  and  insutiicient  secretions.  .  Foreign  bodies  lodged  in.  the  am- 
pulla of  the  rectum  often  assume  a  position  just  above  the  internal 
sphincter,  and  can  be  felt  by  the  finger  when  they  are  in  this  posi- 
tion. Poly^Di  and  other  neoj^lasms,  strictures,  procidentia,  and  inflam- 
matory conditions,  may  also  be  diagnosed  by  this  means.  A  knowl- 
edge of  the  sensation  imparted  to  the  finger  by  the  various  pathologi- 
cal conditions  is  indispensable  to  the  proper  diagnosis  of  rectal  dis- 
eases. The  soft,  irregular  edges  of  a  tubercular  or  simple  ulceration, 
and  the  hard,  indurated  feel  of  the  sjoecific  type,  require  experi- 
ence to  distinguish  them.  The  smooth,  soft,  slimy  feel  of  a  poh^oid 
growth  is  entirely  different  from  the  hard,  nodular  one  of  carcinoma. 
The  true  fibrous  and  the  soft  inflammatory  stricture  give  entirely  differ- 
ent sensations  to  the  touch,  but  it  requires  education  of  this  sense  and 
experience  to  distinguish  them.  The  condition  of  the  prostate  and  the 
uterus  and  its  appendages  should  also  be  carefully  noted  in  digital 
examination  of  the  rectum.  Frequently  we  are  able  to  feel  the  nodular 
surface  of  an  inflamed  cervix  pressing  down  uj)on  and  irritating  this 
organ.  A  prolapsed  ovary  or  retroverted  uterus,  a  fibroid  or  cystic 
tumor,  a  ha?matoma,  or  even  an  extra-uterine  pregnancy,  may  be  made 
out  by  digital  examination  of  the  rectum.  Frequently  sjTnptoms  re- 
ferred to  this  organ  are  due  to  diseases  elsewhere.  A  stone  in  the 
bladder  or  urethral  stricture  may  cause  rectal  symptoms  only.  The 
specialist  in  rectal  diseases  must  therefore  practicalh'  be  an  accom- 
plished gynaecologist  and  genito-urinar}'  surgeon.  He  may  not  do  the 
operative  work  of  such,  but  so  far  as  the  diagnostic  knowledge  is  con- 
cerned he  should  possess  it  in  both  branches. 

"WTiile  the  finger  is  still  in  the  rectum  the  cocc3"X  should  be  grasped 
between  it  and  the  thumb  externally,  and  moved  backward  and  forward 
to  determine  whether  there  is  any  inflammatory  or  tender  condition 
about  it.  Eectoceles,  both  anterior  and  posterior,  should  be  thoroughly 
explored  for  foreign  bodies  or  hardened  fsecal  masses.  As  the  finger  is 
withdrawn,  if  the  patient  is  requested  to  bear  down,  internal  hemor- 
rhoids, if  present,  will  frequently  follow  it  out  through  the  anus.  If 
there  is  blood,  mucus,  or  pus  in  the  rectum,  it  will  also  follow  the  finger 
upon  withdrawal. 

The  odor  is  also  important.  That  imparted  by  carcinoma  in  the 
rectum,  once  smelled,  can  never  be  forgotten;  that  of  ulceration,  whether 
simple,  specific,  or  tubercular,  is  entirely  different.  There  is  a  feculent, 
sickening,  dead  smell  to  the  discharge  from  a  carcinoma  which  is  pro- 
duced by  no  other  disease. 

Examination  by  the  finger  is  practically  limited  to  the  first  -i 
inches  of  the  rectum.     With  the  patient  bearing  down  and  the  surgeon 


110  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

pressing  upward  upon  the  perinaniui,  the  thunilj  being  carried  back 
over  the  coccyx  and  the  fingers  over  the  peringeum,  or  vice  versa, 
another  ^  inch  can  possibly  be  gained;  but  4^  inches  is  the  limit  of 
digital  touch.  Where  the  disease  is  higher  up  some  other  method 
must  be  adopted. 

Introdudion  of  the  Hand  into  the  Rectum — Manual  Examination. — 
Extending  the  principle  of  tactile  examination,  Simon,  of  Heidelberg, 
demonstrated  in  1872  the  feasibility  of  introducing  the  whole  hand 
into  the  rectum  for  the  purposes  of  examination.  In  order  to  accom- 
plish this,  the  patient  must  be  anaesthetized,  and  the  hand  should  be 
thorouglily  lubricated.  The  fingers  are  introduced  into  the  anus  one 
after  another,  and  the  sphincter  muscles  gradually  stretched  until  the 
palm  and  finally  the  whole  hand  is  introduced.  The  dilatation  must 
be  very  slow  and  with  a  boring  motion.  After  the  hand  passes  through 
the  grasp  of  the  sphincter  muscle  it  will  slip  into  the  widest  portion 
of  the  rectum,  where  the  space  is  ample.  This  portion  of  the  rectum 
is  not  covered  by  the  peritonaeum,  and  there  is  little  danger  of  injury, 
as  it  is  very  distensible.  From  this  point  upward,  however,  the  gut 
grows  narrower,  and  if  Houston's  valves  are  much  developed,  there  will 
be  points  at  which  there  is  a  partial  constriction.  After  the  hand  has 
been  carried  from  4  to  5  inches  upward  general  constriction  will  begin 
to  be  felt,  whether  the  gut  is  normal  or  diseased,  and  from  here  on 
the  greatest  gentleness  and  care  are  necessary  to  avoid  traumatism  to 
the  gut.  In  the  first  portion,  above  the  great  ampulla  of  the  rectum,  the 
peritonaeum  covers  the  front  surface  of  the  gut,  and  as  we  ascend  it 
passes  more  and  more  to  the  sides,  until  it  finally  entirely  surrounds 
the  intestine  on  a  level  with  the  third  piece  of  the  sacrum.  At  this 
point,  where  tlie  rectum  joins  the  sigmoid,  one  will  always  find  a  marked 
contraction  in  the  caliber  of  the  gut;  and  the  introduction  of  the  hand 
through  this  is  fraught  with  danger,  unless  the  hand  be  very  small. 
Whatever  examination  can  not  be  made  by  the  introduction  of  two 
fingers  through  this  contracture  had  better  be  left  undone  until  an 
exploratory  laparotomy  shall  clear  up  the  question.  The  dangers  of 
the  latter  are  less  than  the  introduction  of  the  whole  hand  through 
the  recto-sigmoidal  juncture.  Simon  states  that  with  half  of  the  hand 
passed  through  this  contracture,  the  abdominal  cavity  may  be  exam- 
ined to  the  extent  of  several  centimeters  above  the  umbilicus;  one 
rarely  has  occasion  to  pass  his  hand  higher  up  than  this.  According 
to  Simon's  directions,  a  hand  measuring  25  centimeters  (9|  inches)  in 
circumference  may  be  thus  introduced  without  danger.  The  author 
believes,  however,  that  a  hand  that  requires  a  kid  glove  larger  than 
No.  7|  should  never  be  introduced  into  the  rectum  except  in  a  life 
or  death  emergency.     The  danger  of  this  procedure  has  been  discussed 


EXAMINATION   AND   DIAGNOSIS  111 

by  manr  Avriters.  Four  cases  have  been  reported  in  ^vliieli  deatli  fol- 
lowed the  operation.  They  are  as  follows:  H.  B.  Sands  (Xew  York 
Medical  Eecord,  June^  1874,  p.  301)  introduced  a  hand  measuring  19 
centimeters  (Ty^  inches)  in  circumference  12  inches  up  into  the  gut 
(the  arm  being  too  large  to  allow  it  to  pass  any  farther),  but  dis- 
covered nothing  by  this  examination.  One  week  later  he  made  a  sec- 
ond examination,  this  time  introducing  his  right  hand  15  inches  above 
the  anus.  The  circumference  of  this  hand  is  not  stated,  but  it  was 
presumably  larger  than  Ms  left.  By  this  examination  he  diag-nosed  a 
stricture  of  the  ascending  colon.  He  then  did  a  right  lumbar  colot- 
omy.  The  patient  died  from  shock  on  the  following  day.  In  the  speci- 
men removed,  the  "  caput  coli  "  showed  separation  of  the  muscular  fibers 
and  rupture  of  the  peritoneal  coat  at  8  inches  adore  the  anus.  Some  of 
the  longitudinal  muscular  fibers  in  the  sigmoid  were  separated,  but  there 
was  no  rupture  through  the  gut  wall.  We  call  attention  to  the  fact  that 
the  peritoneal  injury  was  not  at  the  rectum  but  in  the  caput  coli,  and 
the  separation  of  the  muscular  fibers  was  apparently  as  much  at  this 
portion  as  in  the  rectum  itself.  Furthermore,  attention  is  invited  to 
the  fact  that  it  was  impossible  for  the  hand  to  have  been  introduced 
up  to  the  caput  coli,  and  therefore  these  iajuries  must  have  been  the 
result  of  the  operation  for  colotomy  and  not  of  the  examination. 

Weir  (Xew  York  Medical  Journal  of  18T5,  p.  411:)  reported  the 
case  of  a  woman,  aged  fifty,  who  complained  of  S}Tnptoms  of  obstruc- 
tion, and  upon  whom  manual  examination  was  performed.  He  was 
unable  to  make  any  diagnosis,  although  he  succeeded  in  touching  the 
kidney  with  his  hand.  A  lumbar  colotomy  was  performed,  and  the 
patient  died  the  next  day.  The  autopsy  revealed  no  peritonitis,  but 
about  two  teaspoonfuls  of  free  blood  in  the  Douglas  cul-de-sac.  There 
was  a  rent  in  the  muscular  and  peritoneal  coats  of  the  bowel  on  its 
anterior  aspect,  just  where  the  peritonseum  is  reflected  from  the  bladder 
upon  the  rectum.  The  mucous  membrane  was  not  ruptured,  and  there 
was  no  evidence  of  peritonitis.  A  close  stricture  of  the  transverse 
colon  was  found  with  a  large  accumulation  of  faecal  matter  above  it. 
The  patient  rallied  from  the  operation,  it  is  said,  and  the  cause  of 
death  seemed  very  obscure.  If  it  had  been  from  rujDture  of  the  bowel 
there  would  have  been  peritonitis  and  other  symptoms  associated  there- 
with. If  from  shock,  it  may  as  well  be  attributed  to  the  operation  of 
colotomy  as  to  the  manual  examination.  The  third  case  referred  to 
by  Weir  (Medical  Eecord,  18T5,  p.  201)  occurred  in  St.  Luke's  Hospital 
under  the  care  of  Sabine.  This  patient  died  at  the  end  of  four  days, 
and  the  post-mortem  examination  showed  a  laceration  of  the  mucous 
coat  of  the  rectum  with  ecchymosis,  but  no  rupture  of  the  gut.  There 
seems  to  have  been  no  perforation  in  any  of  these  cases.     Dandridge 


112  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

(Cinciimati  Lancet  and  Observer  for  18T6)  reported  the  ease  of  a  man 
with  a  psoas  abscess,  who  was  in  the  hospital  with  a  condition  of  sup- 
puration apparent,  but  no  diagnosis  had  been  made.  On  March  22d  the 
doctor  explored  the  rectum  with  his  hand,  passing  it  through  what 
seemed  to  be  a  constriction  of  the  bowel,  as  though  it  were  bound  down 
b}'  a  false  membrane  just  above  the  rectum.  Before  reaching  the  prom- 
ontory of  the  sacrum,  a  large  swelling  posterior  to  the  rectum  was  ob- 
served. The  examiner  proceeded  with  due  care,  exploring  the  surfaces 
of  the  vertebrae,  the  psoas  muscle  on  both  sides  of  the  conunon  iliac, 
and  upward  to  the  bifurcation  of  the  aorta.  His  associate.  Dr.  Connor, 
then  repeated  the  examination.  The  circumference  of  the  hand  is  not 
given  in  either  case.  This  man  suffered  from  surgical  shock  and  tem- 
perature for  three  days,  some  evidences  of  peritonitis  developed  which 
practically  subsided  upon  the  third  day,  after  which  time  the  patient 
developed  pneumonia  and  died  on  the  tenth  day.  The  autopsy  revealed 
septic  pneumonia  with  pus  in  the  pleural  cavities,  and  pleural  adhesions 
showing  evidences  of  an  old  inflanmiation.  There  were  flecks  of  recent 
lymph  throughout  the  peritoneal  cavity  binding  the  loops  of  intestines 
together.  There  was  no  fluid  found  in  the  abdominal  cavity.  The 
mucous  membrane  of  the  intestine  was  normal.  On  the  anterior  surface 
of  the  rectum  there  was  a  slit-like  tear  in  the  peritongeum  about  5 
inches  from  the  anus.  There  was  no  special  evidence  of  inflammation 
in  its  immediate  vicinity.  The  mucous  membrane  corresponding  to 
this  rupture  was  normal.  At  the  same  level,  on  the  lateral  and  pos- 
terior aspect,  there  were  two  abscesses  in  the  wall  of  the  bowel.  Just 
above  the  sphincter  there  was  a  tear  through  the  mucous  and  muscular 
coat,  but  there  seemed  to  be  no  infection  or  inflammatory  complication 
from  these.  Psoas  abscesses  and  necrosis  of  the  lumbar  vertebras  were 
also  found.  Dandridge  concludes  that  the  peritonitis  was  due  to  the 
rupture  of  the  peritonaeum  5  inches  above  the  anus,  and  to  the  mucous 
membrane  torn  through  just  above  the  sphincter;  and  yet  he  distinctly 
says  in  his  report  that  there  was  no  evidence  of  acute  inflammatioji  around 
either  one  or  the  other  of  these  points.  It  seems  that  with  all  the  .patho- 
logical complications  in  this  case,  it  is  rather  straining  a  point  to  at- 
tribute the  fatality  to  the  manual  examination  of  the  rectum.  Thus, 
taking  the  four  cases,  one  may  say  that  while  they  show  deaths  fol- 
lowing this  procedure,  only  one  of  them  (that  of  Sabine)  seems  to 
be  clearly  due  to  it.  These  cases  have  been  somewhat  extensively 
reviewed,  because  they  are  so  often  quoted  to  show  the  fatal  results  of 
such  examinations.  They  do  not  appear  to  be  conclusive.  At  the  same 
time  one  should  not  underestimate  the  dangers  of  this  method.  In 
malignant  diseases,  in  ulcerations,  and  in  cases  in  which  atheroma  of 
the  arterial  system  exists,  it  should  not  be  undertaken.     But  in  cases 


EXAMINATION  AND  DIAGNOSIS 


113 


of  foreign  bodies  and  of  fsecal  impaction  in  the  sigmoid  flexure,  the 
coats  of  the  bowel  being  otherwise  healthy,  or  for  purposes  of  exploring 
the  pelvic  cavity,  under  the  same  conditions  it  may  be  safely  carried 
out,  provided  the  hand  of  the  operator  does  not  measure  over  20  centi- 
meters (7|  inches)  in  circumference.  The  author  has  done  it  more 
than  a  hundred  times,  and  has  not  yet  had  any  unfortunate  results 
further  than  a  temporary  incontinence  of  faeces,  which  lasted  for  about 
ten  days  in  one  case  and  less  in  others.  While  this  method  is  useful 
and  still  has  its  place  in  rectal  surgery,  it  has  been  largely  superseded 
in  the  last  few  years  by  the  advances  made  in  instrumental  examina- 
tions of  the  rectum. 

Instrumental  Examination  of  the  Rectum. — Liglit. — In  all  methods 
of  instrumental  examination  of  the  rectum,  the  question  of  light  is  a 
very  important  one.  It  can  hardly  be  gainsaid  that  reflected  daylight 
is  generally  the  most 
satisfactory  for  rectal 
examination.  Wlien 
this  can  not  be  ob- 
tained, the  electric 
light  is  the  best  sub- 
stitute. In  large  cities 
or  towns  lighted  by 
electricity  the  street 
current  can  be  used 
for  this  purpose.  An 
ordinary  hand  -  lamp 
with  a  reflector  around 

it  can  be  used  to  throw  the  light  directly  into  the  rectum,  or  it  may  be 
reflected  from  a  head-mirror.  The  illustration  (Fig.  57)  shows  an  electric 
head-light  which  is  more  satisfactory  than  any  other,  and  which  for  gen- 
eral illumination  of  the  lower  rectum  and  operative  work  is  all  that  can  be 
desired.  For  deep  examinations  it  does  not  focus  as  perfectly  as  the  re- 
flected light,  and  is  therefore  not  so  good.  In  smaller  places,  where  there 
is  no  street  current,  or  in  the  country,  some  form  of  storage  or  dry-cell 
battery  will  be  found  useful.  Small  electric  batteries  are  in  the  market 
which  furnish  a  light  of  about  6  candle-power.  They  are  easily  portable, 
and  some  of  them  have  ingenious  attachments  .which  make  them  very 
useful  in  other  instrumental  examinations.  A  little  care  in  the  manage- 
ment of  these  batteries  and  renewing  the  cells  occasionally  is  all  that 
is  necessary  to  supply  a  most  efficient  and  reliable  light  for  the  treat- 
ment of  rectal  diseases.  The  same  batteries  are  also  used  for  illumi- 
nating purposes  in  the  pneumatic  proctoscopes,  which  will  be  described 
later  on.  The  complicated  gaslight  brackets  and  lamps  with  condensing 
8 


Fig.  57. — Electric  Head-light. 


114 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


lenses  are  troublesome  and  no  longer  necessary  since  the  electric  light 
can  be  so  easily  obtained. 

Attached  to  the  Martin  chair  is  an  apparatus  with  many  compli- 
cated screws  and  joints  for  directing  the  light  into  the  rectum.  The 
inventor  uses  it  with  great  dexterity,  but  others  have  been  unable  to 
do  so  satisfactorily. 

A  very  useful  light  for  night  and  country  practice  is  that  known 
as  the  acetylene  bicycle-lamp.  This  burns  for  a  long  while  after  it  has 
once  been  charged,  and  gives  a  very  bright  and  concentrated  light, 
which  can  be  used  either  directly  or  by  reflection.  One  of  these  lamps 
of  small  pattern  is  a  very  convenient  adjunct  to  a  general  operating  bag. 

Kelsey  advises  carrying  in  such  a  bag  a  quantity  of  magnesium 
strips  which,  being  burned,  produce  a  very  bright  light  for  examina- 
tions at  the  patient's  house.  To  one  in  the  habit  of  using  the  pneu- 
matic proctoscope,  such  aids  will  be  unnecessary,  inasmuch  as  he  will 
always  carry  along  with  him  the  little  battery  belonging  to  this  instru- 
ment, and  this  will  supply  abundant  light.  One  of  the  best  of  these 
batteries  is  made  by  the  American  Endoscopic  Company. 

Specula. — Formerly,  that  portion  of  the  intestine  above  5  inches 
was  practically  a  terra  incognita.  Within  the  past  few  years,  however, 
thanks  to  Howard  Kelly,  we  have  become  as  familiar  with  the  appear- 
ance of  the  upper  portions  of  the  rectum  as  we  are  with  that  of  the 
vagina  or  any  other  open  cavity  of  the  body. 

The  old-fashioned  specula  only  gave  us  a  partial  view  of  the  first 
4  or  5  inches.  Tliey  served  their  purposes  very  well,  and  as  instru- 
ments for  treatment  some  of  them  are  even  now  superior  to  many 
of  the  modern  instruments,  but  their  field  is  very  limited.     The  intent 


Fig.  58. — Kelsey's 
Rectai-  Speculum. 


Fig.  59. — Conical  Bivalve 
Rectal  Speculum. 


of  every  speculum  is  to  afford  a  good  view  of  as  much  of  the  rectum 
as  possible.  As  will  be  seen  at  a  glance,  the  instruments  illustrated 
(Figs.  58,  59,  60)  afford  only  a  partial  view  of  the  circumference  of 
the  intestine,  and  a  very  limited  view  of  its  length.  The  Sims's  rectal 
speculum  (Fig.  61)  would  give  a  very  fair  view  of  the  anus  and  rectum 


EXAMINATION  AXD  DIAGNOSIS 


115 


for  4:  inches  np,  provided  the  patient  had  fortitude  enough  to  bear  the 
pain;  hut  where  there  are  haemorrhoids,  polj^Di,  or  tumors  of  the  rectum, 

they  prolapse  into  the  fenestra  of 
the  wire  blades,  and  being  caught 
cause  great  pain  upon  withdra\ral 
of  the  instrument.     It  should  not 


Fig.  60. — Ga^tt's  Opeeatixg  Eectal  SpEcrLrii. 


Fig.  61.— Siiis's  Eectal  SpECULnr. 


Fig.  62. — O'Xeill's  Eectai, 
Speculuil 


be  used  except  under  general  anaesthesia.     The  same  objection  may  be 
offered,  only  in  a  less  degree,  to  the  Kelsey  speculum. 

The  O'Xeill  specu- 
lum (Fig.  62),  which 
undertakes  to  combine 
in  one  the  biyalve  and 
fenestrated  conical 
specula,  is  sometimes 
a  very  useful  instru- 
ment. The  blades  are 
likely,  however,  to 
pinch  the  folds  of  the 
mucous  membrane  or 
hsemorrhoidal  develop- 
ments and  cause  con- 
siderable pain.  It  only 
gives  an  imperfect  view 
of  about  4  inches  of 
the  rectum. 

The  speculum  illus- 
trated in  Fig.  63,  devised  by  the  author,  is  a  modification  of  the  Brinck- 
erhoff  speculum,  with  two  fenestra.    By  a  turn  of  one-quarter  of  a  circle 


Fig.  63. — Authoe's  Co^^cAL  FE^^:s- 

TEATED    SpECULUir. 


116 


THE  ANUS,  RECTtll,  AXD   PELVIC  COLON 


it  gives  a  view  of  the  entire  circumference  of  the  rectum;  it  is  made 
in  two  sizes,  one  3  inches  and  the  other  6  inches  long,  thus  practically 
giving  a  view  of  about  5  inches  of  the  rectum.  Up  to  the  time  of  Kell3^'s 
paper  in  1895,  this  was  probably  the  most  satisfactory  speculum  for 
rectal  examination,  and  it  is  still  a  very  useful  instrument  in  the  local 
treatment  of  ha?morrhoids,  diseases  of  the  crypts  of  Morgagni,  internal 
blind  fistula,  and  ulcerations  in  the  lower  portion  of  the  organ. 

A  small  lar}Tigoscoi3ic  mirror  may  be  used  in  connection  with  this 
instrument  in  order  to  obtain  a  perfect  view  of  the  anterior  and  pos- 
terior cnls-de-sac  of  the  rectum  which  dip  down  behind  and  in  front 
of  the  internal  sphincter.  This  mirror  also  serves  to  examine  the 
crj'pts  of  Morgagni,  and  to  determine  any  fistulous  openings  about  the 
lower  portion  of  the  rectum. 

The  ordinary  Sims's  vaginal  speculum,  such  as  is  possessed  by  every 
surgeon,  has  been  variously  modified  by  Van  Buren,  Kelsey,  Helmuth, 
and  others  (Fig.  61).  The  modifications  all  consist  in  removing  one 
end  of  the  speculum  and  adding  a  straight  handle  so 
that  the  buttocks  will  not  interfere  with  its  introduc- 
tion into  the  rectum.  These  are  all  useful  instruments 
and  the  rectal  specialist  should 
possess  them;  but  to  the  general 
practitioner  they  are  not  a  neces- 
sity, for  he  can  get  along  very 
well  with  the  ordinary  Sims's 
speculum.  For  use  in  connection 
with  this  instrument  one  should 
possess  some  sort  of  a  rectal  re- 
tractor. I  have  found  Pratt's 
(Fig.  65)  very  satisfactory,  al- 
though the  physician  may  easily 
arrange  one  for  himself  out  of 
stiff  copper  wire,  bending  it  to 
suit  his  own  convenience. 

The    self-retaining    speculum 
of  Mathews  (Fig.  66)  is  a  favorite 
one   with  many  operators,   espe- 
cially in  the  West;  but  it  is  open  to  the  same  objections  that  have 
been  mentioned  in  reference  to  the  Sims's  rectal  speculum. 

Formerly  the  Ferguson  tubular  vaginal  speculum  was  used  by  the 

introduction  of  a  rectal  bougie  through  it  as  an  obturator,  and  thus 

introduced  into  the  rectum.    It  formed  a  very  satisfactory  instrument 

for  the  examination  of  this  organ  so  far  as  the  instrument  reached. 

In  1863,  Bodenliamer  introduced  to  the  profession  a  long  steel  tube 


Fig.  64— Vax  Buren's 
Eectal  Speculum. 


Fig.  65, — Pratt's 
Rectal  Eetractor. 


EXAMINATION  AND  DIAGNOSIS 


117 


Fig.  66. — Mathews's  Eectal 
Speculum. 


arranged  witli  a  sort  of  a  spiral  conformation  which  made  it  flexible  at 
the  end,  and  thus  enabled  him  to  pass  it  into  the  sigmoid  flexure.  He 
said  by  this  means  and  a  system  of  mirrors  he  could  observe  the  condi- 
tion of  the  gut  above 
the  recto-sigmoidal 
juncture,  and  also  the 
mucous  membrane  of 
the  rectum  all  the  way 
as  he  withdrew  it.  The 
instrument  was  never 
generally  adopted. 

Andrews,  of  Chica- 
go, later  on  devised 
what  is  known  as  his 
tubular  specula,  one 
being  straight  and  the 
other  cm'ved  so  as  to 
conform  with  the  curv- 
atures of  the  rectum. 
He  claimed  that  with  this  instrument  he  was  able  to  examine  the  sig- 
moid flexure,  and  to  thoroughly  observe  all  its  circumference  by  the 
aid  of  a  concave  mirror  which  is  introduced  into  the  speculum  after 
the  obturator  is  withdrawn. 

Cook,  of  Indianapolis,  also  devised  a  tubular  speculum  similar  to 
Andrews^s. 

The  advice  in  regard  to  their  use  by  the  inventors  is  to  lay  the 
patient  upon  the  side,  introduce  the  sj)eculum,  and  examine  the  mucous 
membrane  of  the  intestine  as  it  prolapses  over  the  end  of  the  instru- 
ment upon  its  withdrawal.  The  principle  of  atmospheric  ballooning  or 
pneumatic  distention  is  never  hinted  at  in  any  of  their  writings,  nor  in 
any  of  the  books  upon  rectal  diseases  in  which  these  tubes  are  described 

and  recommended. 

In  1895,  Kelly,  of  Johns  Hop- 
kins Hospital,  introduced  to  the 
profession  a  set  of  rectal  and  sig- 
moidal  tubes  of  different  calibers 
and  lengths,  designed  for  examin- 
ing the  rectum  and  sigmoid  flexure. 
Fig.  67.— Kelly's  %  I  There  were  no  curves  to  these  in- 

Peoctoscope.  NiJ  struments  (Fig.  67).     The  inventor 

showed,  if  not  for  the  first  time,  at  least  more  forcibly,  that  a  straight 
instrument  could  be  introduced  through  the  anus  into  the  sigmoid  and 
up  to  the  descending  colon.     Not  only  was  this  principle  illustrated, 


118  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

but  the  application  of  the  ballooning  of  the  rectum  by  atmospheric 
pressure  was  brought  into  prominence  as  an  adjunct  in  the  use  of  tubu- 
lar specula. 

Marion  Sims,  in  1845^  demonstrated  to  the  world  the  advantages 
of  atmospheric  pressure  in  ballooning  the  vagina.  Van  Buren,  in  1870, 
demonstrated  to  his  class  in  Bellevue  Hospital  the  application  of  this 
method  to  the  rectum;  at  the  same  time  he  gave  credit  to  Dr.  Sims  for 
the  discovery.  Allingham  advised  the  use  of  this  method  and  devised 
a  tube  for  it;  he  also  accords  to  Dr.  Sims  the  honor  of  priority.  But 
none  of  these  authors  had  undertaken  the  scope  of  examination  which 
Kelly  introduced,  nor  had  any  of  them  used  in  this  way  the  cylindrical 
tubes,  either  short  or  long.  To  Kelly,  therefore,  belongs  not  the  inven- 
tion of  a  tube,  still  less  the  discovery  of  the  inflating  power  of  atmos- 
pheric pressure,  but  simply  their  practical  and  ingenious  application 
to  rectal  surgery.  He  popularized  the  method,  one  may  say,  or  at 
least  showed  us  its  possibilities.  His  method  is  given  in  his  own  words: 
"Anaesthesia  is  unnecessary  in  using  most  of  the  specula  which  are 
of  small  caliber,  and  none  of  the  various  manipulations  are  painful. 
The  patient  kneels  on  an  ordinary  table  (a  common  kitchen  table  is 
quite  convenient)  with  the  elbows  spread  out  at  the  sides  so  as  to  bring 
the  chest  as  close  to  the  table  as  possible,  while  the  thighs  are  perpen- 
dicular to  it,  supporting  the  pelvis  as  high  as  possible.  The  buttocks 
are  drawn  apart,  and  the  blunt  end  of  the  obturator  is  laid  on  the 
anus,  which  is  coated  with  vaseline.  The  direction  of  introduction 
should  be  at  first  downward  and  forward,  and  when  the  sphincter  is 
well  passed,  up  under  the  sacral  promontory.  The  moment  the  specu- 
lum clears  the  sphincter  area,  and  the  obturator  is  withdrawn,  the  air 
rushes  in  audibly  and  distends  the  bowel.  The  bowel  is  illuminated  in 
the  following  manner:  a  strong  light — daylight  will  answer,  but  an  elec- 
tric light  is  most  convenient — is  held  close  to  the  sacrum  where  a 
head-mirror  directs  the  rays  through  the  tube  into  the  bowel."  He 
recommends  as  a  practical  set  of  these  instruments  (Fig.  B8)  sufficient' 
for  all  ordinary  purposes,  a  short  proctoscope  14  centimeters  (5|  inches) 
long  and  22  millimeters  (|  of  an  inch)  in  diameter;  a  long  proctoscope 
of  20  centimeters  (7f  inches),  and  a  sigmoidoscope  of  35  centimeters 
(13j  inches),  all  being  of  the  same  diameter. 

For  examining  the  extreme  lower  end  of  the  anus,  a  proctoscope  of 
5  centimeters  (2  inches)  or  less  will  be  found  convenient,  and  for 
treatment  and  operations  in  the  rectum,  tubes  of  various  diameters  will 
be  needed.  Long  applicators  or  dressing-forceps,  specially  devised  for 
use  through  these  tubes,  are  necessary  to  wipe  away  mucus  and  adherent 
ftecal  masses  which  obstruct  the  view.  A  curette  or  scoop  (Figs.  69,  70), 
devised  by  Kelly,  is  very  useful  for  removing  fgecal  masses  and  curet- 


iiir.  i;^.— Kelly's  Set  of  Ixstbuments  for  exahixixg  the  Eectum  and  Sigmoid. 
fl,  sponge-holder;   b,  applicator;    c,  curette;    d,  anal  dilator;    e,  anoscope;   f,  g,  proctoscopes; 

h,  sigmoidoscope. 


119 


\ 


120  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

ting  small  ulcerated  areas,  as  well  as  for  obtaining  specimens  of 
neoplasms  for  microscopic  examination.  Along  with  this  set  of  instru- 
ments Ivelh-  introduced  a  conical  sphincter  dilator  (Fig.  71).     It  is  a 


Fig.  69. — Kelly's  Eectal  Curette, 


useful  instrument,  although  not  a  necessary  one.  Kelly's  description 
of  the  use  of  the  long  sigmoidoscope  is  rather  enthusiastic.  He  says: 
"  Upon  introducing  the  sigmoidoscope,  the  longest  speculum,  the  instru- 
ment is   continued 


i 


up  into  the  dilated 
sigmoid  flexure  in 
the  false  pelvis  by 


0 

y  Fia.  TO.-Kelly's  Eectal  Scoop.  turning  the  handle 

to  the  right.  At 
some  point  in  the  passage  the  atmospheric  distention  ceases,  and  the 
lumen  of  the  bowel  can  then  only  be  showTi  farther  by  cautiously  push- 
ing the  end  of  the  instrument  on  through  the  lax,  collapsed  folds." 

From  this  one  would  judge  that  there  was  little  or  no  difficulty 
in  passing  from  the  rectum  into  the 
sigmoid  flexure,  even  with  the  obtura- 
tor of  the  instrument  withdrawn;  but 
such  a  statement  is  unintentionally 
misleading.  „  ^^  ^  ^ 

.^^        °  iiG.  71. — Kelly's  Sphincter  Dilator. 

Where  the  sphincter  is  relaxed, 
the  coccyx  movable,  and  the  angle  of  flexure  between  the  sigmoid  and 
the  rectum  is  not  acute,  the  straight  instrument  may  be  introduced  into 
the  sigmoid  flexure  with  comparative  ease;  especially  is  this  true  in 
women.  But  where  the  opposite  conditions  exist,  where  there  is  spasm 
at  the  recto-sigmoidal  juncture,  or  where  the  sigmoid  is  bound  down 
in  the  pelvis,  this  introduction  is  not  only  difficult,  but  extremely  pain- 
ful and  dangerous  as  well.  When  the  gut  is  well  distended  the  instru- 
ment may  be  so  directed  as  not  to  impinge  upon  the  walls;  but  un- 
fortunately this  distention  from  atmospheric  pressure  ceases  ordinarily 
in  the  first  loop  of  the  sigmoid,  and  from  this  point  upward  the  edges 
of  the  tube  scrape  against  the  walls  of  the  gut  and  frequently  wound 
them. 

Ana?sthesia  is  advised  by  some  for  making  such  examinations;  the 
author,  however,  is  opposed  to  this,  believing  that  the  sensations  of 
the  patient  are  the  safest  guide  as  to  how  much  pressure  shall  be  used 


Fig.  72. — Author's  Modification  of 
Kelly's  Sigmoidoscope. 


EXAMINATION  AND    DIAGNOSIS  121 

in  order  to  avoid  injury  to  the  parts.  Moreover,  there  have  been 
noticed  occasionally,  after  sigmoidoscopy  under  chloroform,  a  temporary 
paralysis  of  peristaltic  action  and  great  difficulty  in  reestablishing  the 
regular  faecal  movements.  The  exact  pathology  of  this  condition  can 
not  be  stated,  but  it  is  one  of  those  complications  which  may  follow 
the  use  of  these  instruments. 

In  order  to  overcome  the  difficulty  of  passing  the  straight  instru- 
ment around  the  promontory  of  the  sacrum,  the  author  devised  a 
modification  of  the 
Kelly  tube,  which 
consists  in  the  intro- 
duction of  a  flexible 
obturator  by  which  the 
instrument  is  given  a 
Mercier  curve  (Fig.  72). 
By  this  an  inclined 
plane  comes  in  contact  with  the  promontory  of  the  sacrum,  and  one  is 
able  to  pass  this  point  more  easily  and  with  less  pain  than  with  the 
straight  instrument.  The  modification  is  only  useful  in  the  longer  in- 
struments necessary  for  examining  the  sigmoid. 

Martin  has  devised  a  modification  of  the  obturator  in  the  Kelly 
tubes,  which  consists  in  the  introduction  of  certain  grooves  through 
which  ointments  may  be  applied  to  the  inside  of  the  rectum.  This 
obturator  is  also  perforated,  so  that  one  may  inject  air  or  fluids  into 
the  bowel  while  the  speculum  is  in  position.  Beach  has  also  modi- 
fied the  instrument  by  carrying  an  electric  light  to  its  inner  end 
through  a  supplementary  tube,  a  principle  employed  in  the  endoscope 
and  cystoscope.  The  successful  use  of  all  these  instruments,  however, 
depends  upon  atmospheric  dilatation  of  the  rectum  and  sigmoid.  The 
patient  must  be  placed  in  the  uncomfortable  knee-chest  posture,  and 
even  in  this  position  cases  will  occasionally  be  seen  in  which  the  atmos- 
pheric pressure  will  fail  to  balloon  the  parts.  In  the  majority  of 
cases  this  ballooning  ceases  in  the  first  loop  of  the  sigmoid,  and  noth- 
ing more  can  be  seen  above  this  area  than  that  portion  of  the  mucous 
membrane  which  collapses  over  the  open  end  of  the  instrument.  The 
author  has  found  in  a  number  of  cases,  in  which  there  had  been 
chronic  proctitis  or  attacks  of  pelvic  cellulitis  with  adhesions  of  the 
uterus  and  ovaries  to  the  rectum,  that  the  latter  organ  did  not  balloon, 
and  examination  by  these  tubes  was  very  unsatisfactory.  Such  diffi- 
culties have  led  to  the  development  of  artificial  means  for  distending 
the  rectum. 

PneumaUc  Prodoscoptj. — In  1890,  Dr.  Franz  Heuel,  after  having 
experimented  with  his  inflating  endoscope,  also  made  an  attempt  to 


122 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


introduce  the  principle  into  proctoscopy.  This  is  referred  to  in  order 
to  give  credit  to  the  man  who  first  attempted  practical  pneumatic 
proctoscopy,  although  this  instrument  was  of  little  value. 

In  1899,  Pen- 
nington, of  Chica- 
go, introduced  an 
instrument  known 
as  his  pneumatic 
proctoscope.  This 
apparatus  consists  in 
a  tube  closed  by  an 
accurately  fitting 
glass  cap,  so  that 
the  rectum  can  be 
distended  by  air 
pumped  into  it  from 
a  hand-bulb.  The 
light  is  reflected 
through  the  glass 
into  the  rectum. 
This  method  of  illu- 
mination, however, 
is  not  satisfactory  on 
account  of  refrac- 
tion by  the  glass 
plate. 

Working  at  the  same  time,  and  upon  independent  lines,  Laws,  of 
Philadelphia,  devised  an  instrument  similar  in  many  respects  to  that 
of   Pennington,   but  ,   ^ 

which    is    an    improve-  .^        l       '-rrrrrrrrr.rr'rrr-.-j,     ,j;^^- 

ment  in  that  the 
illumination  is  se- 
cured by  an  elec- 
tric light  carried 
into  the  inside  of 
the  tube  by  insu- 
lated rods  (Figs.  73, 
74).  By  this  means 
the  whole  cavity  is 
well  lighted.  This 
instrument     was     a 

Fig.  74. — Laws's  Proctoscope  with  Aperture  in  Window 
great      improvement  ^^r  Therapeutic  Applications. 

on   any  hitherto   de-  m,  curette ;  N,  palpator ;  0,  spray ;  P,  wire  snare. 


Fig.  73. — Laws's  Pneitmatio  Proctoscope. 
E,  i,  2, 3,  obturators ;  A,  B,  C,  tubes  of  different  sizes ;  D,  han- 
dle ;  F,  cap  with  glass  window  ;  G,  inflating  bulb ;  JT,  battery 
connection ;  J,  K,  electric  light  and  insulating  rods. 


EXAMINATION  AND   DIAGNOSIS 


123 


vised,  but  certain  features  in  it  detracted  from  its  usefulness.  The 
cap  which  closes  the  instrument  is  attached  by  a  screw-thread  which 
sometimes  binds,  and  thus  necessitates  uncomfortable  manipulation  of 
the  instrument  in  adjusting  it;  the  electric  light  occupiQs  a  considerable 
portion  of  the  caliber  of  the  tube  and  thus  obstructs  the  vision  to 
some  extent.  If  there  is  much  secretion  or  fgecal  matter  in  the  bowel, 
this  is  liable  to  flow  down  over  the  end  of  the  light  and  obscure  it, 
thus  requiring  its  removal  and  cleansing  before  the  examination  can 
be  continued;  this  is  tedious  and  annoying,  and  often  results  in  the 
breaking  of  the  lamp.  These  objections  are  not  vital.  They  are  over- 
come by  a  modification  of  the  instrument  devised  for  the  author  by  the 
Electro  -  Surgical  In- 
strument Company,  of 
Eochester  (Fig.  75). 

Author's  Pneumatic 
Proctoscope. — This  in- 
strument is  composed 
of  a  large  cylinder  (F), 
into  one  part  of  the  cir- 
cumference of  which  is 
fitted  a  small  metallic 
tube  closed  by  a  flint- 
glass  bulb  at  its  distal 
end.  The  electric  lamp 
(G)  is  fitted  upon  a 
long  metallic  stem,  and 
carried  through  the 
small  cylinder  to  the 
end  of  the  instrument, 
as  is  shown  in  the  illus- 
tration. 

The  proctoscope  is 
introduced  through  the 
anus  with  the  obturator 
(A)  in  position.  As  soon  as  the  internal  sphincter  is  passed,  this  ob- 
turator is  withdrawn  and  the  bayonet-fitting  plug  (B),  which  contains 
either  a  plain  glass  window  or  a  lens  focused  to  the  length  of  the 
instrument  to  be  used,  is  inserted  in  the  proximal  end  of  the  instrument. 
This  plug  is  ground  to  fit  air-tight,  and  thus  closes  the  instrument 
perfectly.  The  plug  being  inserted  in  the  tube,  a  very  slight  pressure 
upon  the  hand-bulb  will  cause  inflation  of  the  rectal  ampulla  to  such 
an  extent  that  the  whole  rectum  can  be  observed  and  the  instrument 
can  be  carried  up  to  the  promontory  of  the  sacrum  without  coming  in 


Fig.  75. — Tcttle's  Pneumatic  Peoctoscope. 
A,  obturator ;  B,  plug  with  glass  window  closing  end  of  tube ; 
C,  handle;  D,  cords  connecting  instrument  with  battery; 
E,  inflating  apparatus  ;  F,  main  tube  of  proctoscope. 


124  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

contact  with  the  rectal  wall.  Further  dilatation  will  show  the  direction 
of  the  canal  leading  into  the  sigmoid,  and  by  a  little  care  in  manipulating 
the  instrument  and  keeping  the  gut  well  dilated  in  advance,  it  can  be 
carried  up  into  this  portion  of  the  intestine  without  the  least  traumatism 
of  the  parts.  If  any  faecal  material  obscures  the  light  by  being  massed 
or  smeared  over  the  glass  bulb  the  plug  can  be  removed,  and  a  pledget 
of  cotton,  introduced  with  a  long  dressing-forceps,  will  wipe  this  off  so 
that  the  plug  can  be  reintroduced  and  the  examination  continued  with 
very  slight  delay  or  inconvenience. 

The  adjustable  handle  (C)  fits  on  the  rim  of  the  instrument  and 
thus  converts  it  into  a  Kelly  tube.     This  instrument  is  operated  with 

an  ordinary  dry  bat- 
tery of  four  cells.  It 
is  better,  however,  to 
have  one  with  six 
cells,  as  it  will  not 
require    being    re- 

char^'^ed      so      fre  — 
Fig.  76. — Tuttle's  Long  Sigmoidoscope  with  Flexible  Ob-  ° 

TURATOR    giving   THE    INSTRUMENT   THE    MeRCIER    CuBVE.  qUCntly. 

The  tubes  are 
made  of  various  lengths,  from  4  to  14  inches.  The  very  long  ones 
are  supplied  with  the  flexible  obturator,  which  gives  them  the  Mercier 
curve  (Fig.  76),  like  that  in  the  author's  modification  of  the  Kelly  tubes. 

For  the  beginner  in  the  use  of  this  instrument  it  is  better  to  have 
a  plain  glass  window  in  the  plug,  for  magnifying  lenses  are  very  likely 
to  mislead  him  with  regard  to  the  pathological  conditions. 

The  4-inch  instrument  enables  one  to  examine  the  entire  rectum, 
but  does  not  give  any  view  of  the  sigmoid  flexure.  The  10-inch  tube 
is  sufficient  for  any  ordinary  examination  of  the  rectum  and  sigmoid, 
but  one  should  also  have  the  4-inch  size  for  convenience.  The  very 
long  tubes  are  very  rarely  called  for,  but  they  are  useful  in  large  indi- 
viduals with  long  sigmoids  or  loose  mesocolons  which  may  possibly  allow 
the  instrument  to  enter  into  the  descending  colon. 

With  this  instrument  it  is  possible  to  see  all  of  the  sigmoid  flexure, 
and  possibly  even  to  enter  the  descending  colon  by  very  careful  manipu- 
lation. Ordinarily  it  does  not  require  any  anaesthesia.  It  can  be  used 
in  the  prone  or  Sims's  position,  and  the  view  which  it  gives  is  incom- 
parably beyond  that  obtained  by  any  other  means. 

In  using  it  one  must  remember  that  the  bright  electric  light 
intensifies  the  coloring  of  the  parts,  and  may  lead  to  false  conclusions. 
Until  one  becomes  familiar  with  the  changes  in  appearance  produced 
by  such  a  light,  it  is  better  to  make  separate  examinations  by  reflected 
daylight  so  as  to  avoid  this. 


EXAMINATION  AND  DIAGNOSIS  125 

Usually  it  is  perfectly  feasible  to  pass  these  tubes  into  the  sigmoid 
flexure  A\dthout  introducing  the  obturator.  The  pneumatic  pressure 
produced  by  the  hand-bulb  straightens  out  this  organ,  causes  it  to  rise 
up  above  the  pelvic  brim,  and  thus  facilitates  the  introduction  of  the 
straight  instrument,  and  at  the  same  time  allows  one  to  see  considerably 
beyond  the  end  of  the  latter. 

It  may  be  suggested  that  there  is  danger  of  rupturing  a  "weakened 
and  inflamed  intestine  by  such  distention,  but  as  a  matter  of  fact  it  is 
never  so  great  as  to  produce  any  such  effect.  Whenever  the  pressure 
assumes  any  force  the  air  will  escape  through  the  sphincter  or  the  plug 
will  slip  out.  In  cases  of  relaxed  sphincter  it  is  necessary  to  apply  a 
collar  of  wet  cotton  or  gauze  around  the  tube,  and  press  it  firmly 
against  the  anus  in  order  to  retain  sufficient  air  to  obtain  ballooning 
and  thus  permit  the  examination.  One  precaution  should  not  be 
omitted,  and  that  is,  when  one  has  finished  his  examination  with  this 
instrument  he  should  remove  the  cap  and  allow  the  air  to  escape  from 
the  sigmoid  and  rectum  before  he  withdraws  the  tube. 

Laws's  instrument  is  supplied  with  a  supplementary  cap,  through 
which  an  applicator  can  be  introduced  and  medicines  applied  to  any 
given  point.  A  curette  for  scraping  ulcers  or  neoplasms  may  be  used 
through  this  aperture.  The  author  has  found  it  more  satisfactory, 
however,  to  locate  the  pathological  condition  which  is  to  be  treated 
right  over  the  end  of  the  tube,  remove  the  cap,  and  then  treat  it.  In 
this  way  there  is  more  room  for  the  use  of  instruments,  and  one  can 
withdraw  and  reintroduce  them  at  pleasure. 

When  the  examination  is  prolonged,  condensation  of  moisture  upon 
the  glass  may  also  obscure  the  view.  To  avoid  this  it  is  well  to  heat 
the  glass  by  dipping  it  in  hot  water  before  tlie  cap  is  screwed  on.  The 
examination  of  the  rectum  according  to  this  method  is  practically  pain- 
less. The  Sims's  position  is  employed  and  is  not  uncomfortable,  and 
the  results  give  the  utmost  satisfaction.  These  instruments  serve  all 
the  purposes  of  the  Kelly  tubes,  and  the  general  practitioner  needs 
only  the  one  set. 

Atmospheric  pressure  in  examinations  of  the  rectum  has  been  made 
use  of  by  Carpenter,  of  Kentucky,  in  connection  with  a  duckbill  specu- 
lum and  a  long  rectal  retractor;  and  by  Martin,  who  describes  a  method 
of  distending  the  anus  with  the  index  fingers  so  that  the  air  rushes  in 
and  dilates  the  rectum,  thus  affording  a  good  view  of  the  parts.  These 
methods  are  ingenious,  but  they  are  not  to  be  compared  with  those 
described  above. 

Tlie  Limit  of  Ocular  Examination. — The  extent  of  the  intestinal 
canal  which  can  be  seen  through  the  rectum  has  greatly  increased  by 
these  modern  methods  of  examination.     Eeference  has  been  made  to 


126  THE   ANUS,   RECTUM,  AND   PELVIC   COLON 

the  pussibility  of  examining  the  descending  colon.  For  a  long  time  the 
author  was  under  the  impression  that  he  had  been  able  to  do  this,  but 
numerous  experiments  made  upon  the  cadaver  convinced  him  that  this 
was  practicall}'  impossible.  Abbott,  of  Minneapolis  (American  Gynsec. 
and  Obstet.  Jour.,  July,  1900,  p.  20),  has  duplicated  these  experiments 
and  arrived  at  the  same  conclusions. 

According  to  his  measurements  a  straight  tube  passed  farther  than 
12  inches  would  impinge  against  the  liver  or  diaphragm.  There  is  no 
doubt  that  he  is  correct  in  the  statement  that  a  12-inch,  ordinary 
Kelly  tube  is  as  long  an  instrument  as  is  ever  necessary.  With  a  pneu- 
matic proctoscope  of  this  length,  however,  one  may  examine  the  entire 
sigmoid  flexure,  and  very  occasionally  where  the  mesentery  of  the 
descending  colon  is  very  long,  may  possibly  see  into  this  portion  of  the 
intestine.  In  the  large  majority  of  instances,  however,  the  field  of 
ocular  examination  is  limited  to  the  sigmoid  flexure. 

Probes. — The  ordinary  little  silver  probe,  4  to  5  inches  long  and 
rounded  at  both  ends,  is  practically  useless  in  examination  of  the 
rectum.  These  instruments  should  be  8  or  10  inches  long,  and  fur- 
nished with  a  handle  flattened  and  roughened  on  one  side  so  that  it 
can  be  manipulated  with  ease,  and  the  operator  can  always  tell  in  which 


Fig.  77. — Author's  Silver  Probe. 

direction  the  end  is  pointing  (Fig.  77).  They  should  be  made  of  pure 
silver  in  order  that  they  may  be  bent  in  all  directions  throughout  their 
entire  length  without  danger  of  breaking. 

As  an  instrument  to  locate  the  internal  openings  of  fistulre  the 
author  has  practically  discarded  the  probe  until  the  patient  has  been 
anassthetized,  for  one  can  do  this  quite  as  well  by  digital  touch  and 
with  much  less  pain.  After  the  patient  has  been  anaesthetized  the 
instrument  is  of  great  value  in  following  the  tortuous  course  of  the 
fistulous  tracts  as  they  pass  through  the  cellular  and  muscular  tissues 
about  the  anus  to  reach  the  rectum.  A  very  fine  probe  made  of  pure 
silver  is  often  useful  in  internal  blind  fistula?,  and  especially  in  de- 
termining diseases  of  the  cr^-pts  of  !Morgagni. 

Bedal  Scoops. — Another  instrument  which  is  of  great  use  and  should 
be  possessed  by  every  operator  upon  rectal  diseases  is  that  known  as 


Fig.  7S. — Tittle's  Rectal  Spoox. 


the  rectal  scoop.     That  of  Kelly  is  made  of  hard  steel,  is  sharp,  and 
can  not  be  bent.     The  smaller  scoop  (Fig.  78),  made  of  soft  copper, 


EXAMINATION  AND  DIAGNOSIS  12T 

is  the  one  which  the  author  most  frequently  uses  to  scrape  off  hard 
faecal  masses,  cleanse  the  crypts  of  Morgagni,  or  curette  ulcers. 

Applicators  and  Dressing-forceps. — Applicators  and  dressing-forceps 
are  necessary  instruments  in  rectal  examinations.  They  should  be  long 
enough  to  reach  through  the  proctoscope  and  cleanse  the  field  of  ob- 
servation. One  should  have  a  number  of  applicators  so  it  will  not  be 
necessary  for  him  to  stop  and  reapply  the  cotton  as  he  proceeds  in  his 
examination;  they  should  not  have  roughened  ends  or  screws.  By  a 
little  care  and  manual  dexterity  one  can  apply  cotton  on  a  perfectly 
smooth  wire  so  that  it  will  not  slip  off,  but  can  be  removed  without 
difficulty. 

These  instruments  should  be  of  different  lengths,  as  the  very  long 
ones  necessary  for  the  sigmoidal  tubes  are  not  convenient  to  use  in  the 


Fig.  79. — Author's  Deessing-foeceps. 

shorter  instruments.  Long,  straight  dressing-forceps  (Fig.  79),  with 
handles  slightly  bent  downward  so  that  the  hand  will  not  obscure  the 
view,  is  the  most  useful  form. 

In  addition  to  this  one  should  also  have  a  pair  of  long  alligator 
forceps  (Fig.  80)  by  which  he  can  reach  and  seize  small  foreign  bodies, 
polypi,  or  villous  growths  for  the  purpose  of  removal  or  examination. 
These  forceps  are 
useful  because  they 
can  be  opened  and 
shut  in  a  much 
smaller  space  than  -c     oa     a  t?  u 

^      _  hia.  80. — Alligator  Forceps  foe  Use 

those  in  which  the  through  Proctoscope. 

joint  is  in  the  mid- 
dle of  the  shaft.  Tenacula  and  fixation  forceps  are  also  necessary  in  the 
examination  of  the  rectum.  The  double-spring  tenaculum  of  Burns, 
to  catch  the  rectum  and  draw  it  downward,  might  sometimes  be  very 
useful.  The  advantages  of  such  an  instrument  would  principally  be 
to  obtain  specimens  for  microscopic  examination.  Sponge-holders  are 
practically  superseded  at  the  present  day  by  the  dressing-forceps  or 
applicators. 

Blu7it  HooTcs. — There  are  a  number  of  varieties  of  these  of  different 
shapes  and  sizes  useful  for  the  examination  of  the  cr5rpts,  pockets, 
valves,  and  internal  blind  fistulge  of  the  rectum.  By  having  these 
instruments  one  is  able  to  save  considerable  time  and  trouble  in  bend- 
ing and  twisting  his  probes  to  the  proper  shape;  but  their  possession 


128  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

is  not  a  necessity,  for  a  pure  silver  probe  can  be  turned  into  a  blunt 
hook  of  an}'  angle  in  a  moment's  time. 

Bougies  and  Sounds. — Before  the  days  of  tubular  specula  bougies 
and  sounds  were  made  much  use  of  to  examine  by  the  sense  of  touch 
those  portions  of  the  rectum  above  the  reach  of  the  finger.  At  present 
they  are  not  so  much  used  for  this  purpose,  although  some  surgeons 
still  adhere  to  them  as  diagnostic  means.  They  are  of  great  use  in  the 
treatment  of  strictures,  certain  forms  of  prolapse,  and  catarrhal  condi- 
tions of  the  sigmoid  flexure,  but  of  comparatively  little  value  in  diag- 
nosis. They  are  made  of  various  forms,  sizes,  and  materials.  Tliey 
are  conical,  cylindrical,  and  fashioned  after  the  urethral  bougie  d  houle. 
In  general  it  may  be  stated  that  hard,  stiff  rectal  bougies  are  very 
dangerous  instruments^  and  should  never  be  used  above  the  lower  4 
inches,  if  indeed  they  have  any  place  at  all  in  rectal  surgery.  The 
old  English  rectal  bougie  was  made  of  web  and  shellaced,  thus  making 
a  smooth  surface,  which  by  soaking  in  hot  water  became  more  or  less 
flexible.  It  was  more  useful  than  the  hard-rubber  bougies  on  this 
account,  and  until  the  introduction  of  the  Wales  instrument  was  the 
one  most  generally  used.  These  instruments  were  made  conical  and 
cylindrical.  At  one  time  it  was  quite  the  fad  in  England  for  people 
suffering  from  constipation  to  go  by  certain  offices  on  their  way  to 
business  and  have  these  instruments  passed. 

Other  rectal  sounds  are  made  of  metal  and  vertebrated  so  that  they 
bend  in  all  directions.  The  objections  to  such  instruments  are  that 
the  joints  become  rust}^  they  lose  their  flexibility,  and  they  are  very 
liable  to  break  off  in  the  rectum. 

In  1883  Dr.  Wales  introduced  to  the  medical  profession  a  modi- 
fied rectal  bougie  composed  of  soft  rubber.     He  describes  it  as  fol- 


lows: "A  conduit  inins  through  the  center  and  terminates  in  the 
point  of  the  bougie  for  the  purpose  of  commanding  a  stream  of 
water  that  might  be  required  at  any  moment  to  facilitate  the  intro- 
duction of  the  instniments.  The  points  of  the  bougies  are  made  in 
various  shapes — spherical,  conical,  and  olivary — with  the  view  of  meet- 
ing the  necessities  of  special  cases.  The  surface  is  perfectly  polished, 
which,  by  reducing  friction,  increases  the  facility  of  introduction  and 
eliminates  the  unpleasant  sensation  of  dragging  caused  by  a  rough 
instrument "  (Medical  Chronicle,  Baltimore,  1883).  Some  of  these  in- 
struments are  made  with  a  sort  of  bell-shaped  concavity  with  sharp 
edges  in  the  olivary  tips.     This  is  very  objectionable,  and  in  selecting 


EXAMINATION  AND  DIAGNOSIS  129 

a  set  it  is  advisable  to  avoid  these.  A  conical  is  better  than  an  olivary 
end  (Fig.  81).  These  instruments  are  introduced  by  thoroughly  lubri- 
cating them,  and  passing  them  gently  upward  until  an  obstruction  is  met. 

An  ordinary  Davidson  bulb  syringe  is  then  attached  to  the  instru- 
ment, and  a  stream  of  water  is  carried  through  in  order  to  push  out 
of  the  way  any  folds  of  mucous  membrane  or  masses  of  faecal  matter 
which  may  obstruct  its  passage.  In  this  manner  the  rectum  is  dilated 
by  the  fluid,  and  the  bougie  will  pass  unobstructed  to  the  promontory 
of  the  sacrum  if  there  be  no  stricture  to  prevent  it.  At  this  point 
some  little  pressure  is  necessary,  and  the  stream  of  water  should  be 
persistently  carried  through  in  order  to  pass  this  flexure.  After  the 
instrument  has  once  entered  the  sigmoid  flexure  the  force  of  the  stream 
will  lift  the  folds  of  mucous  membrane  from  in  front  of  it,  and  it  will 
pass  without  difiiculty  into  the  gut.  If  it  is  long  enough  and  quite 
flexible,  it  may  be  even  passed  into  the  descending  colon.  These  are 
by  all  means  the  most  satisfactory  rectal  bougies,  both  for  the  general 
practitioner  and  for  the  specialist.  They  are  made  in  different  sizes, 
being  numbered  from  1  to  12.  The  smaller  sizes  are  excellent  instru- 
ments to  give  high  enemata  or  rectal  lavage.  "Wales  also  introduced 
with  this  bougie  a  thin  rubber  cap  or  sheath,  which  he  used  as  a  dilator 
for  strictures  after  the  instrument  had  passed  through  the  same.  This 
sheath  was  tied  to  the  bougie,  and  air  or  water  was  pumped  into  it  until 
it  dilated  two  or  three  sizes  above  that  of  the  bougie,  thus  stretching 
the  stricture  by  a  soft  and  elastic  pressure.  The  ordinary  "Wales  bougie 
is  about  12  inches  long.  This  is  not  sufficient  to  reach  and  enter 
the  descending  colon.  The  author  is  not  aware  that  "Wales  ever  recom- 
mended their  being  made  any  longer;  but  "Wyeth,  of  New  York  city, 
has  had  made  for  him  a  set  of  these  instruments  26  inches  long,  includ- 
ing the  sizes  6  to  10.  These  long  instruments  may  be  used  with  great 
satisfaction  in  diseases  of  the  sigmoid  flexure  and  descending  colon,  and 
are  a  most  desirable  addition  to  our  armamentarium. 

The  rectal  bougie  a  houle  (Fig.  82)  is  a  very  useful  instrument  to 
determine  the  length  or  extent  of  a  strictu.re.  After  the  latter  has  once 
been  established  and  the  size  of  the  opening  in  it  has  been  determined, 


-Trw"-~- 
FiG.  82. — Eectal  Bougie  a  boule. 


these  little  acorn-shaped  bougies  may  be  passed  through  it,  and  upon 
withdrawal,  owing  to  their  obtuse  base,  will  catch  and  thus  more  or 
less  accurately  show  the  height  to  which  the  contracture  extends.  They 
are  made  of  hard  rubber  or  flexible  wire,  with  different  sized  tips  which 
can  be  screwed  on  according  to  the  case  in  which  they  are  to  be  used. 


130  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

The  stem  is  very  flexible  and  can  be  bent  in  any  direction.  They  are 
best  nsed  through  a  cylindrical  speculum.  The  latter  is  passed  up  to 
the  stricture,  the  bougie  a  houle  is  carried  through  it  and  then  through 
the  stricture.  By  this  means  it  is  possible  to  see  accurately  the  opening 
into  the  stricture  and  avoid  any  undue  manipulation  and  force  in  the 
introduction  of  the  bulbous  bougie  into  it.  Andrews,  of  Chicago,  has 
devised  an  instrument  of  this  kind  made  upon  an  inflexible  stem,  and 
bent  so  as  to  conform  to  what  he  considered  the  normal  curve  of  the 
rectum,  but  this  form  of  instrument  does  not  seem  equal  to  the  other. 

In  some  cases  local  examination  fails  to  determine  the  nature  and 
cause  of  rectal  disease.  The  condition  may  be  al)ove  the  point  of  exam- 
ination, or  the  manifestations  may  be  so  obscure  that  it  is  impossible 
to  determine  their  exact  pathology.  In  neoplasms,  one  should  alwa3's 
remove  a  specimen  for  microscopic  examination  before  finally  deciding 
upon  their  malignancy.  In  other  obscure  conditions,  a  careful  analysis 
of  the  discharges  and  of  the  fscal  contents  of  the  bowels  is  necessary. 

Examination  of  Faeces.* — Examination  of  the  f<^ces  is  accomplished 
by  four  methods : 

Macroscopieal,  Microscopical,  Bacteriological,  and  Chemical. 

Fseces  are  the  materials  discharged  from  the  bowels,  made  up  in 
greater  part  of  the  remains  of  food  after  the  process  of  digestion. 
Associated  with  these  remains  are  fluids  secreted  from  the  digestive 
tract,  desquamated  epithelial  cells,  bacteria  in  large  numbers,  and  occa- 
sionally fortuitous  substances,  such  as  parasites  and  their  ova,  blood, 
pus,  gall-stones,  etc. 

In  health  from  140  to  200  grammes  per  day  are  discharged  by  an 
adult.  Though  varying  within  wide  limits,  they  are  usually  of  a  light- 
brown  color.  Certain  foods  and  medicaments  may  cause  them  to  be- 
come very  dark  or  even  black,  as  after  the  ingestion  of  huckleberries 
or  iron.  Again,  w'hen  the  flow  of  bile  is  impeded  they  may  become 
light  3'ellow  or  gray.  In  certain  forms  of  enteritis,  as  in  typhoid  or 
cholera,  they  may  become  gray  or  green. 

Commonl}^  the  evacuations  take  place  once  every  twenty-four  hours, 
but  it  is  not  uncommon  to  find  persons  in  perfect  health  whose  evacua- 
tions occur  but  once  in  forty-eight  hours,  and  again  others  whose  habit 
it  is  to  evacuate  twice  in  twenty-four  hours.  In  pathological  states 
these  intervals  may  vary  from  ten  to  fourteen  days  or  more  on  the  one 
extreme,  to  intervals  of  a  few  minutes  on  the  other. 

In  a  healthy  individual  the  fasces  are  of  a  pasty  or  dough-like  con- 
sistence, and  are  molded  to  the  shape  of  the  bowel,  sometimes  as  long, 
sausage-shaped  segments  or  a  series  of  boluses  closely  massed  together. 

*  For  this  section  the  author  is  indebted  to  Dr.  F.  M.  Jeffries,  director  of  the 
New  York  Polyclinic  Laboratory. 


EXAMIXATIOX   AXD   DIAGNOSIS  131 

Disturbances  of  digestion  quickly  alter  this  consistence  from  tlie 
hard,  dry  masses  of  constipation  and  the  dry,  clay-like  stools  of  liver 
disturbances  to  the  fluid  and  watery  stools  of  a  simple  enteritis,  or  of 
the  gi-aver  disturbances,  such  as  tj-phoid  or  cholera. 

•  In  addition  to  the  observations  as  to  color  and  consistence  many 
constituents  may  be  observed  macroscopically.  Blood  or  pus  in  large 
quantities  may  be  recogTiized  as  such;  seeds  of  fruits  and  vegetables 
appear  unchanged,  and  in  the  lienteric  states  all  kinds  of  food  pass 
through  wholly  unaffected.  The  writer  once  had  submitted  to  him  for 
examination  a  pint  or  more  of  bodies  about  the  size  of  hickory  nuts 
which  a  patient  was  said  to  be  passing  regularly,  and  which  proved  on 
examination  to  be  halves  of  orange  segments  sans  mastication,  sans 
digestion.  The  writer  has  also  seen  pills  and  even  compressed  tablets 
appear  unaffected  in  the  dejecta. 

Skins  and  seeds  of  fruits  and  vegetables,  as  of  apples  and  toma- 
toes, usually  are  readily  recognizable,  as  also  are  shreds  of  vegetable 
fibers. 

Enteroliths,  which  are  gall-stones,  may  sometimes  be  found,  and  are 
of  a  considerable  degree  of  importance  as  an  aid  to  diagnosis.  They 
may  readily  be  overlooked,  as  they  are  frequently  soft  and  of  a  clay-like 
consistence;  but  a  chemical  and  microscopical  examination  will  de- 
termine their  character. 

Mucus,  which  normally  serves  to  coat  the  fasces  when  properly 
formed,  may  sometimes  become  greatly  increased  and  constitute  a  con- 
spicuous part  of  the  stools.  In  cases  of  mucous  colitis  the  greater  part 
of  each  movement  may  be  made  up  of  mucus,  and  frequently  it  fairly 
forms  a  mold  of  the  intestine  and  is  passed  as  long  strands  of  a  struc- 
tureless, more  or  less  tough,  whitish  mass.  Osier  reports  an  autopsy 
where  such  a  condition  existed,  and  says  that  the  intestine  was  lined 
as  with  a  membrane,  and  that  upon  its  removal  the  mucosa  appeared 
to  be  uninjured. 

In  ulcerations  of  the  intestine  the  stools  may  occasionally  contain 
fragments  of  intestinal  mucosa. 

From  their  characteristics  the  stools  of  various  diseases  have  re- 
ceived names  suggested  by  their  appearance,  as,  for  example,  pea  soup 
in  typhoid,  rice-water  in  cholera,  and  tarry  in  yellow  fever. 

Tlie  characteristic  odor  of  normal  faeces  is  due  to  the  decomposi- 
tion of  the  food  residue  and  to  the  secretion  of  glands  about  the  anus. 
This  odor  varies  in  part  according  to  the  nature  of  the  food  ingested. 
In  some  diseased  conditions  it  becomes  very  pronounced  and  disagreea- 
ble, and  is  largely  due  to  micro-organisms.  Pure  cultures  of  some  of 
these  micro-organisms  impart  an  odor  which  is  readily  recognized  as 
contributing  to  the  faecal  odor. 


132 


THE   ANUS,    RECTUM,   AND   PELVIC   COLON 


Parasites  and  i)arls  of  i)arasites,  many  of  which  are  recognizable 
by  the  unaided  eye,  are  common  constituents  of  the  dejecta.  They 
comprise  a  not  inconsiderable  group,  and,  according  to  the  literature, 
the  list  continues  to  grow. 

It  is  not  within  the  province  of  this  article  to  describe  the  various 
forms  occurring  in  faeces,  but  they  will  simply  be  enumerated  in  the 
order  as  classified  by  Von  Jakscli: 

^l"^«P°^^n  Amoeba  eoli. 


1.  Protozoa 


Sporozoa 


Lil'usoria , 


Represented  by  coccidia. 

iCerconionas  intestinalis. 
Megastoma  entericiim. 
Trichomonas  intestinalis. 
Paramascium  coli. 


'  Cestoda. 


2.  Vermes. 


Platoda 


Annelida, 

order 
Nematoda 


3.  Insects. 


f  Tfenia  solium. 
Taenia  saginata. 
Taenia  nana. 
Taenia  diminuta. 
Taenia  eucumerina. 
Bothriocephalus  latus. 
[  Distoma  hepatieiim. 
I  Distoma  lanceolatum. 

Trematoda ■[  Distoma  Rathouisi. 

Distoma  sinense. 
Distoma  felineura. 
f  Ascaris  lumbricoides. 

Ascaridae <  Ascaris  mystax. 

[Oxyuris  vermicularis. 

Strongylidae Anchylostoma  duodenale. 

rr  ■  1    I      t    1-1        i  Trichoeephahis  dispar. 
Trichotrachelid^    ]  Trichina  spiralis. 

Rhabdonema  )  Anguillula  intestinalis. 

btrongyloides  )  ° 


The  microscopical  characters  of  the  faeces  are  easily  determined. 
In  proceeding  to  examine  under  the  microscope,  the  material  is  spread 
out  in  a  thin  layer  underneath  a  cover-glass  and  examined  with  low 
powers  as  with  |  and  ^  inch  objectives.  It  ma}'  be  necessary  to  dilute 
them  with  water  or  a  3-per-cent  salt  solution  before  they  are  in  a 
condition  for  microscopical  examination.  The  substances  derived  from 
the  food  are  first  to  be  considered. 

1.  Vegetable  cells  unaltered  or  in  various  stages  of  disintegration — 
isolated  or  grouped  as  developed,  some  containing  chlorophyll  but 
most  devoid  of  it. 

2.  Muscle  fibers  recognizable  by  their  structure  but  appearing  swol- 
len and  stained  yellow. 

3.  Fat  and  oil  globules. 

4.  Starch  granules,  hydrated  and  sometimes  unhydrated.  They  may 
be  recognized  by  their  blue  color  when  treated  with  a  weak  iodo-potas- 
sium-iodide  solution. 

5.  Fibrous  tissue  of  white  fibrous  and  yellow  elastic  varieties. 


EXAMINATION  AND   DIAGNOSIS  133 

6.  Detritus.  Granules  large  or  small,  grouped  or  isolated,  pale  or 
dark  in  color. 

7.  Always  associated  with  these  are  bacteria^  which  are  abundant 
and  of  numerous  varieties,  prominent  among  which  are  the  Bacillus 
coli  commune  and  the  Bacillus  proteus  vulgaris.  Kone  of  the  bacteria 
normally  found  are  of  pathogenic  character,  although  they  may  exhibit 
pathogenicity  at  times. 

8.  Molds  and  yeast  fungi  are  frequently  associated  with  the  bac- 
terial flora. 

In  pathological  states  the  bacteria  may  increase  to  an  enormous 
amount  and  the  fteces  may  contain  pathogenic  bacteria,  as  the  typhoid 
bacillus  in  typhoid  fever,  the  comma  bacillus  in  Asiatic  cholera.  Tuber- 
cle bacilli  may  be  found  in  cases  of  tubercular  ulcerations. 

The  detection  of  the  pathogenic  bacteria  is  not  a  simple  procedure, 
and  should  be  left  to  the  bacteriologist. 

9.  From  the  intestinal  tract  itself  epithelial  cells  are  constantly 
shed.  They  may  appear  normal  or  in  all  stages  of  disintegration,  ac- 
cording to  the  length  of  time  they  have  constituted  a  part  of  the  stools. 
They  are,  as  a  rule,  stained  yellow. 

By  far  the  most  important  microscopical  elements  of  the  fasces 
are  the  animal  parasites.  Some  of  these  are  microscopical,  and  others 
have  ova  which  would  escape  detection  without  microscopical  examina- 
tion. 

Amcebi  coli,  which  belongs  to  the  rhizopoda,  is  found  in  certain 
dysenteric  stools,  and  occurs  usually  in  tropical  or  subtropical  regions. 
It  can  not  be  distinguished  from  the  Proteus  amoeba,  so  common  in 
the  waters  of  all  localities.  It  is  merely  a  mass  of  protoplasm  devoid 
of  a  cell-membrane,  possesses  a  nucleus  and  one  or  more  vacuoles. 
The  protoplasm  is  granular,  and  frequently  contains  cells  and  granules 
of  detritus  which  it  has  devoured.  It  exhibits  the  same  motility  notice- 
able in  its  prototype,  the  Proteus  amoeba.  It  may  be  as  small  as  a  leu- 
cocyte, or  so  large  as  nearly  to  fill  a  field  of  a  -g^-inch  objective.  In  cases 
where  its  presence  is  suspected  the  stools  should  be  examined  perfectly 
fresh  and  should  be  kept  warm.  In  selecting  material  for  such  exam- 
ination, gather  up  the  particles  of  viscous  or  jelly-like  material.  Such 
stools  may  be  kept  on  hand  for  future  examinations  if  a  little  carbonate 
of  soda  be  added  and  they  be  kept  at  about  the  body  temperature. 

A  variety  of  crystals  may  occasionally  be  seen  in  the  faeces. 

Fatty  acids  are  found  in  the  form  of  minute,  short,  slightly  curved, 
colorless  crystals.     They  are  soluble  in  ether. 

The  fatty  crystals  have  been  found  in  abundance  in  alcoholic  stools 
and  the  stools  of  jaundice,  especially  in  children.  They  are  abundant 
in  the  stools  of  infants  during  lactation. 


134  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

Fatty  soaps,  wliich  occur  in  long,  colorless,  needle-like  crystals  ar- 
ranged in  stellate  groups,  may  be  seen.     They  are  not  soluble  in  ether. 

Ha^matoidin  crystals,  usually  somewhat  atypical  in  structure,  of  a 
light-brown  color,  resembling  somewhat  an  irregular  sheaf  of  wheat, 
may  be  found  free  or  enclosed  in  globular  masses  of  a  substance  re- 
sembling mucin.  They  have  been  observed  in  cases  of  chronic  intes- 
tinal catarrh,  as  the  result  of  haemorrhage,  and  also  in  cases  of  nephritis. 

Charcot-Leyden  crystals  are  sometimes  found  in  iseces  as  in  anky- 
lostomiasis. They  are  colorless  and  are  octahedral  in  form,  resembling- 
those  in  semen  and  the  sputum  of  asthmatics.  They  have  been  found 
in  a  variety  of  conditions,  and  by  their  almost  constant  appearance  in 
conjunction  with  the  various  entozoa,  their  presence  may  be  considered 
as  pointing  to  an  infection  by  some  form  of  intestinal  parasite. 

Cholesterin  is  a  normal  constituent  of  the  faeces,  but  its  appearance 
in  crystalline  form  is  unusual.  It  occurs  in  the  form  of  irregular  rhom- 
bic plates  which  frequently  appear  in  groups.  They  are  colorless,  thin, 
highly  refractive,  and  are  soluble  in  ether.  When  treated  with  dilute 
sulphuric  acid  and  tincture  of  iodine  they  give  a  characteristic  reaction 
of  a  violet  color  followed  by  blue,  green,  and  red.  No  diagnostic  im- 
portance can  be  attributed  to  these  crystals. 

Phosphate  of  calcium  in  the  stools  appears  either  as  wedge-shaped, 
colorless  bodies  in  groups,  with  converging  apices,  or  yellowish,  round, 
dumb-bell  or  oval  bodies,  which  are  usually  fissured.  Their  occurrence 
is  rare  and  of  no  clinical  value. 

Calcium  oxalate  crystals,  in  the  pyramidal  form  common  to  urine 
sediments,  frequently  appear  in  the  faeces  in  health  or  disease.  They 
are  in  more  abundance  during  a  vegetable  diet. 

Triple  phosphate  crystals  (ammonio-magnesium-phosphate)  are  com- 
mon to  fluid  stools.  They  are  usually  in  the  form  designated  as  the 
coffin-lid,  and  are  found  only  in  alkaline  stools.  They  are  readily 
soluble  in  acetic  acid. 

Sulphide-of -bismuth  crystals  are  found  in  the  stools  after  the  admin- 
istration of  some  form  of  bismuth.  They  resemble  ha?min  crystals, 
and  are  dark  brown  or  black  rhombic  bodies. 

Bacteriological  Examination. — As  previously  stated,  the  bacteriologi- 
cal examination  belongs  to  the  expert  bacteriologist. 

The  organisms  found  even  in  healthy  stools  are  numerous  and 
diversified,  and  in  many  of  the  inflammatory  conditions  no  new  forms 
have  been  discovered.  In  catarrhal  and  diarrhceal  stools  the  bacterio- 
logical flora  is  extensive.  It  would  appear  that  these  conditions  are 
not  attributable  to  any  one  organism  or  group  of  organisms.  A  germ 
to  be  an  etiological  factor  need  not  at  autopsy  be  found  to  have  invaded 
the  connective  tissues;  the  bacteria  may  produce  their  effect  solely 


EXAMINATION  AND   DIAGNOSIS  135 

through  their  poisonous  products.  Among  those  mentionecV  as  having 
been  etiological  factors  are  streptococcus,  staphylococcus,  Bacillus  pyo- 
cyaneus,  Bacillus  lactis  aerogenes,  Bacillus  coli  commune,  spirillum  of 
Finkler  and  Prior. 

Other  bacteria  are  the  typhoid  bacillus  in  typhoid  fever,  the  cholera 
bacillus  in  Asiatic  cholera,  the  diphtheria  bacillus  in  diphtheritic  en- 
teritis, the  tetanus  bacillus,  the  Bacillus  aerogenes  capsulatus,  and  the 
tubercle  bacillus.  This  last  organism  may  be  discovered  by  the  follow- 
ing procedure: 

If  the  stools  are  fluid,  smear  them  in  a  thin  layer  on  glass  slides, 
or  if  not  fluid,  they  must  be  dissolved  in  water  to  a  pasty  consistence 
and  then  smeared  as  described.  A  number  of  slides  should  thus  be 
prepared,  as  the  great  dilution  causes  the  bacilli  if  present  to  be  widely 
scattered.  After  allowing  the  smears  to  dry  spontaneously  in  the 
atmosphere,  they  must  be  passed  rather  quickly  three  times  through  a 
Bunsen  or  alcohol  flame  to  "  fix  "  them.  Then  immerse  them  for  half 
an  hour  in  the  following  solution: 

Ziehl-N  eel  sen's  Carhol-fuchsin 

Saturated  alcoholic  solution  of  fuchsin 10  c.  c; 

Five-per-cent  carbolic-acid  water 90  c.  c. 

Eemove  from  this  solution,  carefully  wash  in  running  water,  and 
decolorize  for  about  two  minutes  in  a  5-per-cent  solution  of  sulphuric 
acid.  Wash  in  water  again  and  counterstain  for  three  minutes  with 
an  alcoholic  solution  of  methylene  blue.  Wash  finally  in  water,  dry 
between  folds  of  blotting-paper,  and  examine  with  a  y^^-inch  oil  immer- 
sion objective.  If  tubercle  bacilli  are  present  they  will  be  contrasted 
by  their  bright-red  color,  as  all  other  bacilli  present  will  have  reacted 
to  the  blue  dye.  It  must  be  borne  in  mind  that  they  are  never  present 
in  great  numbers,  and  that  before  a  negative  decision  can  be  determined 
the  investigator  must  have  patiently  searched  over  several  preparations. 

The  chemical  examination  of  the  faeces  is  of  little  importance  owing 
to  the  paucity  of  data  that  may  be  obtained  thereby,  or  to  the  failure 
of  such  data  to  be  of  any  clinical  value. 

Mucin  is  a  constant  constituent  of  the  stools.  For  its  detection 
the  stools  are  to  be  dissolved  in  water  and  an  equal  quantity  of  lime- 
water  added.  After  the  mixture  has  stood  for  several  hours  it  is  filtered, 
and  to  the  filtrate  an  excess  of  acetic  acid  is  added.  If  mucin  is  present 
a  turbidity  or  cloudiness  will  appear. 

Albumin  in  the  stools  may  be  detected  by  mixing  them  with  water, 
and  after  allowing  the  mixture  to  stand  a  short  time  it  is  filtered  and 
the  filtrate  rendered  acid  by  the  addition  of  a  small  quantity  of  acetic 


136  THE   ANUS,    RECTUM,   AND   PELVIC   COLON 

acid.  This  is  then  put  in  a  test-tube  and  heated  nearly  to  the  boiling 
point.  If  albumin  is  present  a  cloudiness  will  appear.  It  is  recom- 
mended that  the  test-tube  be  nearly  filled  and  the  upper  portion  only 
be  heated,  so  that  the  lower  unheated  strata  may  be  used  for  comparison. 

For  the  detection  of  peptone  in  the  stools  Von  Jaksch  recommends 
the  following  procedure:  The  stools  are  rendered  pasty  by  the  addi- 
tion of  water,  boiled  and  filtered  while  still  hot.  The  filtrate  is  to  be 
treated  with  acetate  of  lead  to  precipitate  its  mucin;  it  is  then  filtered 
again,  and  the  filtrate,  which  should  be  not  less  than  500  cubic  centi- 
meters in  volume,  is  acidulated  with  hydrochloric  acid.  To  this  add 
phosphotungstic  acid  until  a  precipitate  ceases  to  form.  The  fluid 
is  then  immediately  filtered.  The  precipitate  is  washed  on  the  filter 
with  five  parts  of  concentrated  sulphuric  acid  in  one  hundred  parts  of 
water  until  the  fluid  which  passes  through  is  colorless,  to  get  rid  of  the 
salts.  The  precipitate  is  then  washed  from  the  filter  with  as  little 
water  as  possible.  Place  in  a  watch-glass,  add  barium  carbonate  until 
the  mixture  is  alkaline,  and  then  place  on  a  water-bath  at  the  boiling 
point  and  heat  for  about  fifteen  minutes  and  apply  the  biuret  test  as 
follows:  Treat  with  caustic  potash  and  add,  drop  by  droj),  a  10-per- 
cent solution  of  sulphate  of  copper.  Peptone  is  shown  by  the  formation 
of  a  color  ranging  from  bluish-red  to  violet,  and  varying  in  intensity 
according  to  the  quantity  present. 

Urea  is  one  of  the  normal  constituents  in  the  stools,  and  when  it 
is  desired  to  ascertain  the  total  quantity  of  nitrogenous  substances 
eliminated  in  questions  of  metabolism,  it  becomes  necessary  to  estimate 
the  urea  in  the  stools.  The  method  of  Von  Jaksch  is  here  recom- 
niended.  Before  drying  the  stools  treat  them  with  dilute  acid  to  pre- 
vent the  evaporation  of  ammonia.  Dissolve  the  dried  stools  in  three 
or  four  times  their  volume  of  alcohol,  allow  this  to  stand  twenty-four 
hours  and  filter.  The  precipitate  is  washed  on  the  filter  repeatedly  with 
alcohol,  the  filtrates  are  mixed,  and  the  alcohol  distilled  off.  The  resi- 
due is  treated  with  nitric  acid,  and  the  resulting  crystalline  pulp  allowed 
to  stand  for  some  hours,  when  the  crystalline  masses  which  have  formed 
are  pressed  between  folds  of  blotting-paper,  dissolved  in  water,  and 
treated  with  carbonate  of  baryta  until  carbonic  acid  ceases  to  form, 
and  then  dried  on  a  water-bath.  The  dry  residue  is  then  extracted 
with  boiling  alcohol.  On  evaporation  the  urea  remains  in  long,  slender, 
prismatic  crystals.  The  usual  tests  for  urea  may  be  applied  to  these 
crystals. 

Of  the  carbohydrates  in  the  stools,  starch  and  sugar  are  the  two  which 
will  be  considered. 

Starch,  as  already  stated,  may  be  recognized  microscopically.  To 
test  for  either  starch  or  sugar  the  faeces  should  be  boiled  with  the  water 


EXAMINATION   AND   DIAGNOSIS  137 

and  the  concentrated  filtrate  tested.  For  starch,  use  the  iodo-potassic- 
iodide  solution,  when  its  presence  will  be  manifested  by  a  blue  color. 
For  sugar,  use  Fehling's  or  the  phenyl-hydrazin  test. 

Various  other  substances  which  may  be  found  normally  or  patho- 
logically in  the  faeces  are  hardly  of  sufficient  importance  to  warrant 
mention  in  this  work;  and,  besides,  their  detection  and  estimation  re- 
quire skilled  manipulation  and  elaborate  laboratory  facilities. 

Anaesthesia  in  Rectal  Diseases. — The  patient's  sensation  is  an  impor- 
tant aid  in  the  diagnosis  of  rectal  diseases;  for  this  reason,  because  of 
the  repugnance  of  patients,  and  on  account  of  remote  but  possible  dan- 
gers, general  anaesthesia  should  be  avoided  whenever  possible.  In  most 
cases  examination  can  be  made  by  the  finger,  the  speculum,  the  bougie, 
or  the  sigmoidoscope  with  very  little  pain,  and  in  view  of  the  dangers 
attending  the  use  of  these  instruments  under  general  anassthesia  it  is 
better  to  suffer  slightly  than  to  incur  risks.  Furthermore,  primary 
anaesthesia  is  of  little  use  in  these  examinations,  for  the  anus  is  almost, 
if  not  quite,  the  last  organ  to  lose  its  sensitiveness  and  reflexes;  there- 
fore nothing  short  of  complete  narcosis  is  satisfactory.  Sir  William 
McEwen  (British  Medical  Journal,  1904,  vol.  xi,  p.  233)  has  called 
attention  to  the  dangerous  disturbances  of  respiration  during  opera- 
tions on  the  anus  and  rectum  caused  by  reflex  action  on  the  pneumo- 
gastric  nerve,  and  says  it  is  not  safe  to  begin  such  operations  until  pro- 
found anaesthesia  has  been  attained.  He  suggests  that  this  danger  may 
be  avoided  by  local  anaesthesia  or  hypodermic  injections  of  morphine 
before  etherization,  but  in  examinations  alone,  if  local  anaesthesia  of 
the  anus  can  be  produced,  that  is  all  that  is  necessary. 

In  the  examination  of  hypera3sthetic  patients  general  anaesthesia  is 
occasionally  demanded.  In  such  cases  it  is  advisable,  if  possible,  to 
prepare  the  patient  for  any  minor  operation  that  may  be  necessary  and 
do  it  at  the  same  time.  In  office  practice  these  operations  are  limited 
to  stretching  the  sphincter,  incising  fissures  or  small  fistulas,  removing 
small  isolated  haemorrhoids,  cauterizing  ulcers  and  ligating  polypi.  In 
such  cases  the  inhalation  of  ethyl  chloride  or  nitrous  oxide  gas  produces 
complete  anaesthesia,  and  the  patients  can  safely  walk  out  in  half  an 
hour  afterward.  The  former  requires  no  complicated  apparatus  for 
its  administration,  and  is  practically  free  from  danger.  In  operating 
with  either,  a  small  dose  of  morphine  should  be  given  hypodermically 
about  ten  minutes  before  the  anaesthetic,  to  quiet  mental  excitement 
and  to  forestall  the  acute  pain  attendant  upon  the  rapid  return  of  con- 
sciousness. With  these  drugs  the  surgeon  should  not  begin  operating 
until  narcosis  is  complete;  undue  haste  may  excite  the  patient  and 
allow  a  return  to  consciousness  before  anything  is  accomplished. 

In  operations  consuming  more  than  fifteen  minutes  ether  or  chloro- 


138  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

form  should  be  employed  :  ehloroform  causes  less  nausea,  but  ether  is 
safer,  and  the  nausea  is  largely  prevented  by  the  preliminary  adminis- 
tration of  ethyl  chloride  or  gas.  With  these  drugs  the  morphine  may 
be  withheld  until  the  completion  of  the  operation.  When  using  chloro- 
form the  mask  should  always  be  removed  during  the  stretching  of  the 
sphincter,  as  this  procedure  excites  deep  respiration  and  invites  danger 
from  too  rapid  inhalation  of  the  drug. 

Spinal  anaesthesia  is  useful  in  rectal  operations,  but  further  experi- 
ence is  necessary  to  establish  its  exact  status  in  surgery. 

Local  AncBsthesia. — In  ulcers,  fissures,  and  granulating  wounds  of 
the  anus  the  pain  of  examination  and  treatment  may  be  ameliorated 
by  the  insufflation  of  orthoform  or  ana?sthesin  upon  the  parts,  or  by  the 
application  of  a  strong  solution  (10  per  cent)  of  cocaine.  Xone  of 
these  remedies  has  any  marked  effect  upon  the  unbroken  skin  or  muco- 
cutaneous membrane.  The  mucous  membrane  may  be  anaesthetized  by 
cocaine  or  eucaine,  applied  on  little  pledgets  of  cotton  to  which  threads 
are  tied  in  order  that  the  surplus  may  be  removed  after  five  minutes' 
contact.  The  other  local  antpsthetics  have  proved  practically  useless  in 
rectal  surgery. 

All  minor  operations  upon  the  rectum  can  be  done  with  compara- 
tively little  pain  by  the  hypodermic  injection  of  weak  solutions  of  cocaine 
or  eucaine  into  the  parts,  or  even  by  infiltration  with  cold  water  as 
advocated  by  Gant.  Stretching  the  sphincter,  an  important  part  of 
these  operations,  is  quite  painful  with  such  anaesthesia;  Gant  there- 
fore advises  cutting  this  muscle,  which  departure  from  recognized  surgi- 
cal practice  we  do  not  endorse.  In  the  infiltration  method  there  is  danger 
of  infection  from  punctures  through  tissues  which  it  is  impossible  to 
sterilize,  and  from  sloughing  after  operation.  These  methods  of  anes- 
thesia are  chiefly  useful  in  office  practice,  and  the  extent  of  their  em- 
ployment depends  upon  how  much  operating  one  should  do  and  allow 
the  patient  to  go  out  immediately  thereafter.  To  those  who  believe 
that  it  is  safe  to  tie  off  haemorrhoids,  to  incise  fissures,  and  to  operate 
on  fistulas,  and  let  the  patient  walk  about  at  once,  such  methods  present 
a  large  field  of  usefulness.  Such  practices,  however,  appear  to  invite 
unnecessary  danger,  to  ignore  the  advantages  of  rest  in  a  recumbent 
position  after  all  operations  on  the  rectum,  and  to  minimize  both  the 
operation  and  its  moral  effects.  ]\Ioreover,  one  can  do  more  thorough 
work  unhampered  by  the  restlessness  of  conscious,  anxious  patients. 


CHAPTER    IV 

CATARRHAL  DISEASES  OF   TEE  RECTUM  AND  SIGMOID: 
PROCTITIS  AND  SIGMOIDITIS 

The  structure  of  the  mucous  membrane  and  the  functions  of  the 
rectum  and  sigmoid  render  these  organs  peculiarly  susceptible  to  catar- 
rhal affections.  Not  only  are  they  studded  with  myriads  of  Lieberkiihn 
follicles,  forming,  as  it  were,  little  crypts  for  the  lodgment  of  infectious 
materials,  but  it  is  at  these  ]3oints  that  the  excrementitious  matters  of 
the  alimentary  canal  in  their  most  concentrated  form  lodge  for  varying 
periods  before  being  passed  out  of  the  body. 

The  mucous  membrane  here  absorbs  from  the  fsecal  mass  a  large 
proportion  of  its  fluids,  in  which  are  many  bacteria  and  infectious 
germs.  Here  the  faecal  mass  becomes  hardened  through  this  absorption 
of  its  moisture,  and  by  friction  and  pressure  excoriates,  sometimes  actu- 
ally wounds  the  mucous  membrane,  and  thus  produces  lesions  that 
become  infected  and  result  in  catarrhal  proctitis. 

The  intimate  connection  and  similarity  of  structure  between  the 
mucous  membrane  of  the  rectum,  sigmoid,  and  colon  render  it  impossible 
to  discuss  the  disease  in  one  part  without  taking  into  consideration  the 
others.  j\Ioreover,  inasmuch  as  the  chief  symptoms  of  catarrhal  inflam- 
mation of  the  sigmoid  and  colon  are  often  referred  to  the  rectum  or 
associated  with  some  symptoms  in  this  organ,  it  has  become  the  province 
of  the  rectal  specialist  to  look  into  and  treat  these  diseases  whether 
they  are  confined  to  the  rectal  ampulla  or  extend  to  the  caput  coli 
itself.  Since  the  invention  of  the  modern  instruments  for  examining 
the  sigmoid  flexure,  the  direct  observation  and  application  of  remedies 
to  these  parts  has  simplified  their  treatment  and  in  many  respects 
altered  our  views  entirely  with  regard  to  their  pathology.  It  is  impossi- 
ble in  any  case  of  catarrhal  disease  to  draw  a  dividing  line  where  the 
condition  begins  and  where  it  ends.  In  the  majority  of  cases,  instead 
of  the  inflammation  being  confined  to  the  rectum,  it  extends  throughout 
the  sigmoid  flexure  and  upward  into  the  descending  colon.  There  are 
instances  in  which  the  disease  is  confined  to  the  rectum;  but  it  is  very 
rare  that  there  is  a  catarrhal  colitis  or  sigmoiditis  in  which  the  rectum 

139 


140  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

is  not  more  or  less  involved.  In  considering,  therefore,  the  catarrhal 
diseases  of  the  rectum,  one  can  not  confine  himself  to  this  organ  alone, 
but  must  extend  his  observations  higher  up  in  the  intestinal  canal. 

In  the  acute  form  of  proctitis  one  may  generally  recognize  a  definite 
period  of  beginning,  and  come  to  some  conclusion  with  regard  to  its 
origin;  but  the  chronic  forms  are  so  insidious  in  their  approach  and 
so  devoid  of  positive  symptoms  in  tlieir  early  stages  that  one  can  rare- 
ly tell  how  long  they  have  existed,  their  cause,  or  their  probable  dura- 
tion. 

Catarrhal  inflammation  of  the  lower  end  of  the  intestinal  tract  may 
be  divided  into  two  broad  classes.  Simple  and  Specific. 

Simple  catarrhs  consist  in  acute  catarrhal  inflammation,  atrophic 
catarrhal  inflammation,  hypertrophic  catarrhal  inflammation. 

The  specific  forms  are  gonorrhoeal  catarrhal  inflammation,  diphthe- 
ritic catarrhal  inflammation,  erysipelatous  catarrhal  inflammation, 
dysenteric  catarrhal  inflammation,  syphilitic  catarrhal  inflammation. 

SIMPLE    CATARRHAL    INFLAMMATION 

Inflammations  of  the  nuicous  membrane  which  are  not  due  to 
any  specific  germ  yet  recognized  are  among  the  most  frequent  dis- 
eases of  the  human  race.  Especially  is  this  true  in  large  cities,  and  in 
those  climates  where  the  individuals  are  subject  to  frequent  and  excess- 
ive changes  in  temperature,  overheated  houses,  poor  ventilation,  in- 
dulgence in  stimulating  and  highly  seasoned  foods,  and  the  lack  of 
physical  outdoor  exercise. 

Predisposition. — Individuals  differ  in  their  susceptibility  to  these 
inflammatory  processes.  Some  patients  live  for  years  in  certain  cli- 
mates, resist  the  sudden  changes  and  exposure  that  pertain  to  their 
environments,  indulge  in  almost  all  sorts  of  excesses  with  regard  to 
diet,  and  never  suffer  from  any  catarrhal  disorders;  while  others  develop 
them  on  the  slightest  exposure  or  indiscretion.  Sudden  change  of 
temperature,  alteration  in  diet,  indulgence  in  some  stimulating  food  or 
drink,  or  even  change  of  water,  will  be  followed  in  these  individuals 
by  catarrhal  inflammation  of  the  colon  and  the  rectum.  This  pre- 
disposition is  undoubtedly  hereditary,  for  it  can  be  traced  from  genera- 
tion to  generation  in  families. 

It  is  impossible  to  state  at  what  point  the  disease  most  frequently 
begins.  It  may  develop  at  either  end  of  the  large  intestine,  and  pro- 
gress steadily  toward  the  other  as  long  as  its  treatment  is  neglected. 
In  adults  the  symptoms  and  history  of  the  case  may  give  some  indica- 
tion of  its  origin,  but  in  children  this  is  always  too  unreliable  to  justify 
conclusions  upon  this  point.     We  must  therefore  depend  largely  upon 


PLATE  J. 


NORMAL  MUCOUS 
MEMBRANE 


ACUTE  CATARRHAL 
PROCTITIS 


ATROPHIC  CATARRHAL 
PROCTITIS 


HYPERTROPHIC 
CATARRHAL  PROCTITIS 


FOLLICULAR   PROCTITIS 


ULCERATIVE  PROCTITIS 


INFLAMMATORY  CONDITIONS 
OF  THE  RECTUM  AS  SEEN  THROUGH  THE  PROCTOSCOPE 


CATARRHAL   DISEASES  OP  THE  RECTUM  AND  SIGMOID      141 

local  examination.  Happily  we  can  examine  a  child's  rectum  just  as 
well  as  an  adult's,  and  whenever  persistent  constipation,  diarrhoea,  or 
irregularity  in  the  faecal  movements  of  an  infant  are  discovered,  a 
rectal  examination  should  he  made  at  once.  Within  the  last  year  the 
author  has  introduced  the  small  proctoscope  into  the  sigmoid  flexures 
of  four  children  under  the  age  of  two  years  (one  being  less  than  nine 
months  old)  without  the  slightest  difficulty.  In  three  of  them  a  marked 
catarrhal  inflammation  of  the  lower  end  of  the  colon  was  found,  which 
yielded  readily  to  local  applications,  and  the  patients  were  rapidly 
cured.  The  influence  of  age,  sex,  and  occupation  vary  in  the  different 
types  of  the  disease,  as  well  as  the  symptoms,  and  therefore  it  is  advisa- 
ble to  discuss  each  variety  separately. 

Acute  Catarrhal  Proctitis. — Like  catarrhal  inflammation  in  other 
miTcous  tracts,  this  comes  on  suddenly,  and  may  be  frequently  traced 
to  a  clearly  deflned  exciting  cause.  It  may  be  ushered  in  with  a  slight 
chill,  aching  pains  over  the  body,  especially  in  the  sacrum  and  around 
the  pelvis,  and  slight  elevation  of  temperature.  Generally,  however, 
the  patient  does  not  observe  these  symptoms,  but  describes  the  disease 
as  dating  from  the  first  sensations  in  the  rectum. 

Symptoms. — The  earlier  symptoms  are  fulness  followed  by  a  sense 
of  weight,  heat,  and  burning  in  the  rectum.  If  the  disease  is  ])igh  up 
there  will  be  more  discomfort  than  real  pain,  but  tenesmus,  bearing 
down,  and  desire  to  go  to  stool  will  be  marked.  Pains  that  radiate 
to  the  back,  legs,  and.  pelvic  organs,  difficulty  in  and  a  frequent  desire 
to  micturate,  are  noticed;  the  bodily  temperature  may  be  elevated,  the 
pulse  quickened,  the  tongue  furred  or  coated  white,  and  there  may 
be  headache  or  general  malaise.  The  patient  is  always  more  comforta- 
ble lying  down  than  in  the  erect  posture. 

>Some  describe  a  sensation  as  if  a  foreign  body  was  in  the  rectum 
causing  the  sphincters  to  contract,  and  when  the  bowels  move,  the 
fgecal  matter,  which  is  generally  fluid,  is  ejected  through  the  narrowed 
orifice  in  a  small  forcible  stream. 

If  the  disease  be  severe,  leucorrhoea  or  cystitis  may  be  produced  in 
consequence  of  the  intimate  nervous,  vascular  and  lymphatic  connec- 
tions; but  where  these  occur,  one  should  always  suspect  and  positively 
eliminate  the  gonorrhoeal  element  as  an  etiological  factor  before  he 
concludes  that  he  has  to  deal  with  a  simple  catarrhal  proctitis.  During 
the  first  twenty-four  hours  of  acute  catarrhal  proctitis  there  will  be  dis- 
charged from  the  rectum  a  thin,  fluid  fa?cal  matter;  later  on  this  fluid 
will  be  tinged  with  blood  and  contain  mucus;  if  the  inflammation  per- 
sists and  is  severe,  ulceration  will  take  place;  indeed,  the  whole  mucous 
membrane  of  the  rectum  may  slough  off  and  be  discharged.  After  this 
the  discharges  from  the  rectum  will  be  muco-purulent  or  sanguino-puru- 


142  THE  ANUS,  KECTUM,   AND  PELVIC  COLON 

lent,  the  liveal  materials  being  mixed  with  blood  and  pus  in  large 
quantities. 

From  the  beginning  the  desire  to  go  to  stool  is  frequent  and  impera- 
tive, and  requires  the  patient  to  remain  close  to  the  commode.  The 
act  does  not  relieve  the  desire,  and  the  patient  constantly  strains  to 
rid  himself  of  what  seems  to  be  a  foreign  body  in  the  rectum,  but 
which  is  nothing  more  than  the  inflamed,  swollen,  and  (Edematous 
mucous  membrane.  The  sensation  is  comparable  to  that  of  granula- 
tion of  the  conjunctiva,  where  there  is  constant  desire  on  the  part  of 
the  patient  to  get  rid  of  something  in  the  eye.  In  children  the  mucous 
membrane  frequently  prolapses,  producing  the  condition  described  by 
Koser  as  "  ectropion  recii." 

The  introduction  of  the  finger  or  speculum  is  very  painful,  and 
may  even  require  anaesthesia.  To  the  touch  the  parts  feel  dry,  hot, 
and  swollen  in  the  first  stages;  after  secretion  has  begun  they  appear 
moist  and  slimy,  the  walls  of  the  rectum  seem  close  together,  and  the 
caliber  diminished. 

Through  the  speculum  the  membrane  appears  of  a  bright-red  color 
(Plate  I,  Fig.  2),  dry,  and  cedematous  in  the  beginning;  later  on  the 
color  is  darker  and  the  surface  covered  with  mucus;  occasionally  this 
assumes  the  appearance  of  a  pseudo-membrane. 

The  inflammation  in  acute  catarrhal  proctitis  is  generally  confined 
to  the  mucous  membrane  and  the  submucosa.  Earely  the  deeper  tis- 
sues may  be  involved,  and  even  the  muscular  wall  itself  may  be  per- 
forated, resulting,  as  Kelsey  has  pointed  out,  in  acute  peritonitis  and 
death.  Under  ordinary  circumstances  the  inflammation  subsides  under 
rest  and  proper  treatment,  the  symptoms  grow  less  marked,  and  the 
patient  recovers  in  a  few  days;  at  other  times  the  disease  passes  into 
the  chronic  form.  When  nothing  more  than  the  mucous  membrane 
is  involved,  this  ends  the  acute  phenomena;  but  when  deep  ulceration 
occurs,  perirectal  abscess,  fistula,  or  stricture  may  result. 

Etiology. — Pinworms,  lumbricoids,  impacted  faces,  and  foreign 
bodies  may  all  set  up  a  catarrhal  inflammation  of  the  rectum.  Im- 
proper diet,  such  as  sauces,  highly  seasoned  foods,  hot  tamales,  green 
peppers,  etc.,  are  frequent  causes  of  the  acute  variety.  Chronic  con- 
stipation is  not  very  frequently  the  cause  of  acute  proctitis;  this  con- 
dition is  slow  in  development,  and  the  mucous  membrane  becomes 
accustomed  to  a  condition  which  approaches  by  such  gradual  and  insidi- 
ous steps.  Fermentation  or  putrefaction  in  the  intestine,  which  some- 
times follows  a  change  of  diet,  water,  and  environments,  may  induce  a 
sudden  and  acute  catarrhal  inflammation  of  the  colon  all  along  its 
course.  This  occurs  more  frequent!}'  in  summer  and  in  hot  climates 
than  under  other  conditions. 


CATARRHAL   DISEASES  OF   THE   RECTUM  AND   SIGMOID       143 

Infection  is^,  however,  the  chief  of  causes.  When  the  fa?cal  mass 
reaches  the  sigmoid  flexure  and  rectum,  the  moisture  is  largely  absorbed, 
and  the  hard,  insoluble  substances  are  likely  to  stick  out  beyond  it  and 
thus  irritate  or  wound  the  mucous  membrane.  This  renders  the  lower 
portion  of  tlie  bowel  very  liable  to  infection  from  the  bacteria  always 
present. 

Eheumatism  and  gout  are  closely  related  to  catarrhal  inflammation 
of  the  intestines  (Curling),  but  not  as  etiological  factors.  The  same 
conditions  which  cause  them,  viz.,  fermentation  and  putrefaction  in 
the  intestinal  canal,  are  frequently  the  cause  of  proctitis  and  colitis. 

Prolapse  and  intussusception  may  be  the  cause  of  catarrhal  inflam- 
mation. This  is  brought  about  by  the  friction  of  the  membrane  upon 
itself,  the  irritation  from  the  passage  of  facal  masses  through  a  nar- 
rowed channel,  and  a  circumscribed  interference  with  the  circulation 
of  the  parts.  In  prolapse,  where  the  gut  protrudes  and  recedes  from 
time  to  time,  it  is  irritated  by  this  process  and  by  rubbing  against  the 
clothing;  its  circulation  is  interfered  with  by  contraction  of  the 
sphincter,  and  it  is  desiccated  by  exposure  to  the  atmosphere;  as  a 
result  catarrhal  inflammation  frequently  occurs.  Tumors  of  the  rec- 
tum, uterus,  and  ovaries,  displacements  of  the  uterus,  stone  in  the 
bladder,  and  whatever  causes  undue  and  unnatural  pressure  upon  the 
rectum,  will  cause  a  localized  congestion  at  that  point,  and  set  up  an 
inflammation  which  may  spread  in  all  directions.  It  may  also  be  caused 
by  inflammations  of  the  uterus  and  its  appendages,  the  prostate  and 
seminal  vesicles. 

Sitting  upon  cold  stones  or  wet  seats  is  very  frequently  the  exciting 
cause  of  acute  catarrhal  proctitis.  Coachmen  are  said  to  be  particularly 
liable  to  the  disease  on  this  account.  The  author  has  seen  a  number  of 
cases  in  young  people  who,  after  exciting  exercise,  such  as  tennis,  base- 
ball, or  cricket,  have  sat  down  upon  the  damp  ground,  thus  causing  a 
sudden  chill  to  the  parts,  which  resulted  in  attacks  of  acute  catarrh  of 
the  rectum  and  sigmoid. 

Acute  congestion  of  the  liver  sometimes  terminates  in  catarrhal 
inflammation  of  the  rectum,  due  to  obstruction  of  the  portal  cir- 
culation, and  also,  to  the  irritating  influences  of  excessive  discharges 
of  bile  which  follow  such  attacks.  Mild  attacks  of  this  disease  may 
also  be  produced  by  the  action  of  irritating  cathartics,  such  as  jalap, 
aloes,  gamboge,  rhubarb,  podophyllin,  and  senna. 

Finally,  attention  must  be  directed  to  personal  idiosjmcrasies  with 
regard  to  the  development  of  this  disease.  In  the  author's  experience 
an  acute  catarrhal  condition  of  the  lower  end  of  the  intestinal  tract 
would  be  produced  in  one  individual  by  a  single  cup  of  coffee;  another 
patient  could  never  eat  strawberries  without  having  afterward  an  acute 


U-t  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

rectal  catarrh,  almost  dysenteric  in  its  nature;  another  suffered  from 
this  condition  if  he  drank  a  single  glass  of  ordinary  apple  cider.  These 
idiosyncrasies  might  be  multiplied,  but  they  are  not  pertinent  to  the 
subject;  each  individual  forms  a  problem  in  himself,  and  no  generaliza- 
tion can  be  drawn  from  them. 

Treatment. — The  treatment  of  this  form  of  disease  like  all  others 
demands  the  removal  of  the  cause  if  possible.  When  it  is  due  to 
irritating,  infectious,  or  putrefying  substances  in  the  intestinal  canal, 
they  should  be  evacuated  at  once  either  by  saline  cathartics  or  intestinal 
lavage;  if  there  be  foreign  bodies  or  impacted  faeces  in  the  rectum,  these 
should  be  removed;  but  great  care  should  be  exercised  in  their  removal 
to  avoid  all  traumatism  and  injury  to  the  parts.  The  dilatation  of  the 
sphincters  gives  great  relief  to  the  patient  when  the  catarrhal  inflam- 
mation is  low  down  about  the  margin  of  the  anus. 

Saline  laxatives,  such  as  sulphate  of  magnesia,  sulphate  of  soda, 
cream  of  tartar  and  sulphur;  or  some  of  the  mineral  waters,  such  as 
Rubinat,  Hunyadi  Janos,  or  Apenta  are  exceedingly  useful.  One  should 
not  hesitate  in  the  use  of  these  medicines  to  give  a  sufficient  quantity 
to  produce  a  thorough  washing  out  of  the  parts  by  the  watery  move- 
ments which  they  produce.  Small  doses  do  more  harm  than  good,  and 
even  in  patients  who  are  very  weak  and  debilitated  no  bad  result  fol- 
lows full-sized  doses  of  these  remedies. 

After  the  bowels  have  been  thoroughly  cleaned  out,  antiphlogistic 
remedies  should  be  applied;  irrigation  with  cold  water  is  very  grateful 
to'  most  patients,  to  others  very  hot  water  soothes  the  parts  more 
effectually,  and  in  a  number  of  cases  alternating  currents  of  hot  and 
cold  water  may  be  used  with  very  gratifying  results.  The  hard- 
rubber  rectal  irrigator  (Fig.  83)  of  the  author  and  a  fountain  syringe 

will  be  found  very  satisfactory 

— >_,.^   ..^^  — ^  "^^^^      for  this  purpose.     It  is  made 

,[  .l!^....^'^- .,,.... I     ^.^     i^  various  sizes  so  that  it  can 

""■  '  '  Vv  '^6  used  with  comparative  com- 

M  fort   in   cases   with   both   con- 

*  tracted  and  relaxed  sphincters. 

Fig.  83.— Tuttle's  Rectal  Irkigator.  It    consists    in    a    hard-rubbcr 

cylinder,  through  the  center  of 
wliich  runs  a  small  tube  connecting  with  three  openings  in  the  distal 
end.  This  tube  carries  the  fluid  into  the  rectum.  The  large  cylinder  has 
numerous  openings  upon  the  sides  large  enough  to  admit  of  the  passage 
of  small  fiecal  particles,  and  it  is  connected  at  the  outer  end  with  a  dis- 
charge pipe,  to  which  is  attached  a  rubber  tube  long  enough  to  reach  a 
basin  on  the  floor  when  the  patient  lies  upon  the  bed.  The  instrument 
can    be    taken    apart    and    thoroughly    sterilized.      It    is    used    witli 


CATARRHAL  DISEASES  OF   THE  RECTUM  AND   SIGMOID       145 

the  patient  lying  upon  the  side^  and  any  quantity  of  fluid  can  be 
thus  passed  through  the  rectum  without  wetting  the  bedclothes  or 
necessitating  a  movement  of  the  bowels.  When  the  hot  and  cold  water 
are  alternated  a  Y-tube  is  used  to  connect  the  irrigator  with  two 
syringes  containing  the  water.  By  this  means  therapeutic  agents  may 
be  applied  to  the  parts;  solutions  of  carbolic  acid  .5  to  1  per  cent,  of 
boric  acid  5  per  cent,  of  thymol  2  per  cent,  nitrate  of  silver  1  to  2,000, 
of  hydrastis  1  to  2  per  cent,  of  the  aqueous  fluid  extract  of  krameria  5 
to  20  per  cent.  After  the  irrigation  has  been  continued  ten  to  fifteen 
minutes,  the  fluid  should  all  be  drained  out  of  the  rectum  through 
the  irrigator,  and  a  suppository  of  opium  and  iodoform  introduced. 
The  particular  solution  used  for  irrigation  will  depend  upon  the  indica- 
tions in  each  individual  case.  Krameria  and  nitrate  of  silver  are  the 
most  generally  employed. 

Sometimes  the  parts  about  the  anus  are  so  tender  that  the  intro- 
duction of  the  irrigator  can  not  be  borne.  In  such  instances  two  small 
rubber  catheters  can  be  used,  one  for  the  inflow  and  one  for  the  exit 
of  the  irrigating  fluid.  The  use  of  enemata  is  not  advised  because 
they  only  increase  the  tenesmus  and  the  desire  to  go  to  stool.  Some- 
times after  the  irrigation,  the  introduction  of  a  small  amount  of  flax- 
seed tea,  about  1  ounce,  with  ^  to  1  grain  of  opium  and  30  minims  of 
the  aqueous  fluid  extract  of  krameria  will  prove  very  soothing  to  the 
parts,  and  be  effectual  to  quiet  tenesmus.  Regulated,  unirritating  diet 
should  be  enjoined.  Most  writers  insist  upon  the  use  of  milk,  but  this 
article  is  so  prone  to  produce  hard,  tough  scybalse  which  constipate  the 
individual  and  irritate  the  inflamed  surfaces  by  their  passage  over  them, 
that  thin  gruels,  beef,  mutton,  and  chicken  broths,  or  some  of  the  pre- 
pared foods,  such  as  Mellen's,  Carnrick's,  or  beef  peptonoids,  are  to  be 
preferred. 

After  the  acute  inflammatory  stage  is  passed,  when  suppuration  and 
ulceration  occur,  the  irrigation  with  antiseptic  solutions  should  be  con- 
tinued, and  if  the  disease  is  low  down,  the  rectum  may  be  sprayed  with 
some  astringent  solution,  such  as  nitrate  of  silver  or  argyrol;  powders, 
such  as  bismuth,  aristol,  or  antinosine,  may  be  insufflated  through  a 
tubular  speculum  directly  upon  the  ulcer  if  it  be  isolated,  or  all  over 
the  rectal  wall  if  there  is  general  ulceration,  by  jalacing  the  patient  in 
the  knee-chest  posture  and  obtaining  atmospheric  dilatation.  )Sulphate 
of  copper,  and  also  sulpho-carbolate  of  zinc,  in  mild  solutions,  have 
acted  very  well  as  sprays  in  this  condition. 

The  bowels  should  be  induced  to  move  at  regular  intervals,  and  the 
rectum  should  be  irrigated  after  each  movement.  The  patient  should 
be  kept  in  bed  until  the  pus  and  blood  have  entirely  ceased  to  be  dis- 
charged. The  dietary  regimen,  however,  should  be  kept  up  for  some  little 
10 


146  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

time  after  the  patient  has  got  up.  If  the  disease  is  high  up  in  the 
sigmoid  flexure  or  colon,  lavage  through  the  long  rectal  bougie  should 
be  carried  out  with  the  patient  in  the  knee-chest  posture,  and  large 
quantities  of  the  solution  should  be  introduced:  as  much  as  2  gallons 
of  boric-acid  solution  or  a  l-to-10,000  bichloride  of  mercury  may  be  thus 
introduced.  The  solutions  rapidly  come  away,  and  there  is  no  danger 
from  the  amount  of  the  drug  which  will  be  absorbed. 

Medicines  by  the  mouth  are  not  generally  effective.  Antiferments, 
such  as  beta-naphthol,  salol,  subnitrate  of  bismuth,  and  creosote,  may 
sometimes  be  effectual  in  the  prevention  of  further  fermentation  in 
the  intestinal  canal.  The  enteric  pills,  composed  of  sulpho-carbolate 
of  zinc  and  covered  with  a  coating  which  is  not  soluble  in  the  acid  secre- 
tions of  the  stomach,  are  occasionally  effectual.  These  cases  are  more 
benefited  by  the  use  of  a  pill  that  contains  sulphate  of  copper  |  grain, 
and  extract  of  opium  ^  grain  than'  by  any  other  drugs;  these  are  given 
every  two  hours,  and  the  result  is  sometimes  magical  in  the  relief  of  the 
tenesmus  and  the  tendency  to  diarrhoea.  Castor-oil,  as  a  laxative,  has 
not  proved  as  effectual  in  producing  a  movement  that  is  watery  and 
cleansing  as  have  the  saline  preparations,  and,  moreover,  it  leaves  a  tend- 
ency to  constipation  in  the  patient  which  is  not  satisfactory;  neverthe- 
less, many  authors  prefer  this  to  all  other  laxative  medicines  m  such 
conditions.  In  minute  doses  (5  minims),  repeated  every  two  hours,  it  is 
sometimes  very  soothing  to  the  bowel  and  checks  the  tendency  to  diar- 
rhoea. Fluid  extract  of  hamamelis  and  liquor  of  bismuth,  of  each  from 
1  to  2  drachms,  is  spoken  of  very  highly.  To  the  out-of-town  practi- 
tioners, who  have  not  large  pharmacies  to  order  from,  the  flaxseed  tea, 
witch-hazel,  and  astringent  washes  will  generally  prove  quite  satis- 
factory. 

CHRONIC    PROCTITIS    AND    SIGMOIDITIS 

There  are  two  types  of  chronic  catarrhal  inflammation  of  the  rec- 
tum and  sigmoid,  the  hjpertropliic  and  atrophic.  The  acute  form  may 
merge  into  a  chronic  state,  and  when  this  takes  place  it  generally  de- 
velops into  what  is  known  as  hypertrophic  catarrh. 

Hypertrophic  Catarrh. — This  type  is  sometimes  described  as  acute 
and  chronic,  but  practically  it  is  always  chronic.  It  has  been  confused 
in  some  recent  writings  (Quenu,  Hamonic,  and  Ueclus)  with  proliferat- 
ing rectitis,  which  is  a  syphilitic  inflammation.  It  is  not  confined  to  one 
portion,  but  affects  all  of  the  large  intestine,  the  sigmoid  and  rectum 
as  well. 

PafJwIogical  Anatomy. — The  mucous  membrane  and  submucosa  in 
this  condition  are   always  thickened;  the   glandular   elements   of   the 


CATARRHAL  DISEASES  OF   THE  RECTUM  AND  SIGMOID       147 


Fig.  84. — HYPEBTROpnic  Catarrhal  Proctitis. 

Specimen   sliowiiig  increase  in   depth   of  tubules   and 

intertubular  substance. 


membrane  are  markedly  hypertrophied;  the  Lieberkulm  follicles  are 
deepened,  the  intertubular  substance  is  increased  (Fig.  84),  and  there 
is  an  increase  in  the  number  of  goblet  or  mucus-producing  cells. 
The  connective  tissue  of  the  submucosa  is  increased;  here  and  there 
elastic  fibers  are  found  in 
it,  but  there  is  no  evidence 
of  cicatricial  formation.- 
Around  the  blood-vessels, 
which  are  numerous,  and 
between  them  and  the  true 
mucosa,  is  a  mass  of  em- 
bryonic tissue  of  variable 
thickness.  The  blood-ves- 
sel walls  appear  normal  or 
somewhat  thinned. 

Bacterial  culture  from 
the  scrapings  of  this  con- 
dition show  only  the  spores 
and  bacteria  ordinarily 
found  in  the  intestinal 
tract.  The  muco-pus,  col- 
lected by  scraping,  shows  under  the  microscope  pus-cells,  leucocytes, 
and  various  bacteria,  together  with  small  masses  of  fsecal  matter  and 
undigested  particles  of  food. 

Etiology. — The  cause  of  this  condition  may  be  intra-  or  extra-intes- 
tinal; it  may  follow  acute  colitis  or  proctitis,  or  it  may  develop  from 
the  same  causes  which  produce  these  conditions.  It  may  also  be  pro- 
duced by  conditions  external  to  the  intestine.  Adhesive  bands  which 
constrict  the  colon  or  which  rub  against  it  during  peristaltic  action  may 
cause  congestion,  thus  setting  up  a  hypersemia  and  hyperplasia  which 
eventuate  in  hypertrophic  catarrh. 

Abdominal  tumors  or  displaced  uteri  that  press  upon  the  intestine 
may  excite  this  condition;  movable  kidneys,  especially  those  which 
slide  up  and  down  with  every  respiration,  and  rub  against  the  wall  of 
the  ascending  or  descending  colon,  may  induce,  or  certainly  they  may 
keep  up,  an  inflammatory  condition  of  the  large  intestine  which  ex- 
tends to  the  rectum.  Catarrhal  appendicitis  also  has  its  influence  in 
producing  or  protracting  this  disease.  It  has  frequently  been  held  that 
this  form  of  appendicitis  is  due  to  the  catarrhal  condition  of  the  bowel, 
a  proposition  which  it  is  impossible  to  prove  or  disprove.  The  fact  re- 
mains, however,  that  a  patient  with  a  catarrhal  condition  of  the  colon, 
complicated  by  catarrhal  appendicitis,  will  very  often  recover  very 
promptly  if  the  appendix  is  removed.    Pathology  and  bacteriology  have 


148  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

thrown  no  particular  light  upon  the  etiology  of  this  disease,  and  it  is 
only  from  clinical  observations  that  we  can  draw  our  conclusions.  The 
same  irregularities  in  diet,  habits,  and  exercise  which  produce  acute  ca- 
tarrhal conditions  of  the  intestine  will  also  produce  this.  The  chief  etio- 
logical factor  in  this  disease  is  said  to  be  chronic  constipation. 

Symptoms. — In  the  early  stages  of  this  disease  the  symptoms  are 
vague  and  indefinite,  unless  it  succeeds  an  acute  catarrh,  under  which 
circumstances  there  is  simply  an  amelioration  of  the  acute  symptoms 
and  a  gradual  development  of  the  chronic  condition.  The  disease  is 
not  confined  to  the  rectum;  it  usually  affects  the  sigmoid  flexure  and 
colon  as  well;  hence  the  S3^raptoms  may  be  referred  to  a  wide  area. 
There  are  flatulence,  tenesmus,  loss  of  appetite,  and  general  malaise;  the 
tongue  is  flabby  and  coated  white;  diarrhoea  sometimes  alternates  with 
constipation ;  the  stools  are  either  soft,  semifluid,  and  mixed  with  muco- 
pus,  or  they  may  be  hard  and  round  like  sheep-balls,  and  covered  with 
this  muco-purulent  secretion.  As  the  disease  progresses  the  constitu- 
tional and  digestive  symptoms  become  more  marked;  periodic  tenes- 
mus occurs,  after  which  there  is  a  profuse  passage  of  thick,  glairy  mucus 
mixed  with  pus,  and  sometimes  tinged  with  blood.  The  patient  is  nearly 
always  aware  of  the  approach  of  such  attacks,  and  is  much  exhausted 
after  the  mucous  passages.  There  is  not  much  pain  about  the  lower 
end  of  the  rectum,  but  rather  a  feeling  of  weight  and  discomfort. 

The  secretion  from  the  mucous  membrane  is  abundant,  and  some- 
times it  oozes  out  through  the  sphincter,  keeping  the  anal  tissues  moist 
and  macerated.  Occasionally  this  produces  an  erythema  or  dermatitis 
which  may  be  mistaken  for  moist  eczema.  The  discharge  is  sometimes 
so  profuse  that  a  patient  is  compelled  to  wear  a  napkin.  The  radial  folds 
are  hypertrophied,  and  between  them  there  frequently  occur  small  fis- 
sures, but  as  the  sphincters  are  relaxed  these  are  not  very  painful.  Pru- 
ritus is  one  of  the  most  frequent  symptoms,  and  sometimes  the  only  one 
which  induces  the  patient  to  consult  a  physician.  The  disease  occurs 
most  frequently  in  plethoric,  fat,  flabby  individuals,  but  it  is  also  seen 
in  thin,  neurotic  persons. 

Around  the  anus  one  may  frequently  see  hypertrophies  of  the  papillas 
develop  into  typical  condylomata  with  dendritic  formation.  This  condi- 
tion extends  well  up  into  the  anus,  and  becomes  less  marked  as  the  ano- 
rectal line  is  approached.  The  hypertrophy,  however,  seems  to  begin 
again  in  the  mucous  membrane,  and  extends  indefinitely.  To  the  digital 
touch  the  mucous  membrane  presents  a  soft,  doughy  feeling  with  a  some- 
what closer  approximation  of  the  walls  than  is  normal.  Through  the 
speculum  it  appears  oedematous,  paler  than  usual,  and  covered  with  a  thin 
coat  of  whitish  secretion  (Plate  I,  Fig.  5).  The  swollen  membrane  bulges 
out  into  the  fenestra  of  the  conical  speculum,  or  falls  do^^m  and  complete- 


CATARRHAL  DISEASES  OP  THE  RECTUM  AND  SIGMOID       149 

ly  covers  the  end  of  the  proctoscope.  When  the  muco-pus  is  wiped  off, 
the  membrane  presents  tlirough  tlie  magnifying  glass  a  cauliflower-like 
appearance,  whitish  and  granular.  It  does  not  bleed  easily,  and  the  end 
of  a  fine  probe  being  pressed  down  upon  its  surface,  the  tissues  Avill  meet 
together  above  it.  By  scraping  with  a  rectal  scoop  one  may  obtain  a  cer- 
tain amount  of  muco-purulent  fluid  the  composition  of  which  has  been 
already  mentioned.  Hemorrhages  are  not  characteristic  of  this  dis- 
ease, neither  are  hasmorrhoids.  The  latter  sometimes  develop,  but  they 
are  of  the  connective  tissue  and  not  the  hsemorrhagic  type ;  the  mucous 
membrane  covering  them  is  thickened,  but  the  author  has  never  been 
able  to  establish  the  transformation  from  cylindrical  to  stratified  pave- 
ment epithelium  over  the  parts,  as  has  been  described  by  Hamonic  and 
Quenu. 

There  is  often  a  sensation  after  stool  of  something  more  to  come 
away.  This  may  result  from  a  partial  prolapse  or  from  the  retention  of 
a  certain  amount  of  mucus  in  a  posterior  or  anterior  rectocele.  The  in- 
troduction of  the  finger  into  the  rectum  will  sometimes  result  in  the 
passage  of  this  accumulation,  and  the  patient  will  be  relieved.  After  the 
passages  of  muco-purulent  material  there  is  often  a  burning,  itching  sen- 
sation around  the  anus. 

The  papillae  around  the  upper  margin  of  the  pecten  are  frequently 
much  hypertrophied,  and  the  crypts  of  Morgagni  are  swollen  and  in- 
flamed. Constipation  becomes  a  most  annoying  feature  in  the  later 
stages ;  the  patient  does  not  succeed  in  having  a  movement  of  the  bow- 
els without  the  greatest  effort.  Large  doses  of  laxatives  and  recto- 
colonic  flushing  are  necessary  in  order  to  provoke  a  movement.  In 
the  meantime  between  the  stools  the  patient  suffers  from  an  inclination 
to  defecate,  which  results,  after  more  or  less  straining  and  tenesmus, 
in  the  passage  of  a  small  quantity  of  mucus,  sometimes  tinged  with 
blood  and  pus.  There  are  swelling  of  the  abdomen,  intestinal  griping 
pain,  nausea,  and  vomiting.  The  patients  gradually  develop  vague 
nervous  symptoms,  become  apprehensive  and  hypochondriacal,  or  they 
may  have  grave  mental  symptoms. 

Treatment. — The  treatment  of  this  form  of  catarrh  is  necessarily 
prolonged  and  tedious.  Wliere  a  tumor,  floating  kidney,  displaced 
uterus,  or  tenderness  over  the  appendix  exists,  one  should  not  commit 
himself  to  a  too  favorable  prognosis  from  local  treatment,  for  it  may  be 
necessary  to  operate  for  the  complication  before  a  cure  can  be  obtained. 

It  may  be  asked  why  we  do  not  operate  immediately  in  such  cases. 
If  it  is  an  extremely  chronic  condition,  and  modern  treatment  has  been 
tried  without  effect,  then  it  would  be  perfectly  proper  to  do  so.  But 
where  the  case  is  a  subacute  one,  where  the  condition  has  lasted  only 
two  or  three  months,  where  no  proper  dietary  regimen  and  local  treat- 


150  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

ment  have  been  carried  out,  one  can  not  say  that  all  the  therapeutic 
measures  have  been  exhausted ;  these  should  be  tried  before  any  serious 
operatign  is  undertaken,  provided  life  and  general  health  are  not  endan- 
gered by  such  delay. 

Assuming  that  the  a?tiological  factor  is  intra-intestinal,  the  first  ob- 
ject in  the  treatment  should  be  to  remove  it.  Get  rid  of  whatever  irri- 
tates the  intestinal  mucous  membrane,  whether  it  be  hardened  fgecal 
masses,  fermenting  intestinal  products,  cestodes,  or  whatever  foreign 
substance  may  be  in  the  patient's  bowels  or  rectum. 

The  best  thing  for  such  radical  cleaning  out  of  the  intestinal  canal 
is  sulphate  of  magnesia  5  parts  and  bicarbonate  of  soda  1  part.  A  table- 
spoonful  of  this  mixture  should  be  given  before  breakfast  in  the  morning, 
and  repeated  every  two  or  three  hours  until  a  thorough  watery  evacua- 
tion is  obtained.  After  this  the  colon  should  be  flushed  with  2  or  3 
quarts  of  boric  acid  or  normal  saline  solution.  The  patient's  hips  should 
be  elevated,  or  he  should  be  placed  in  the  knee-chest  posture;  the  solu- 
tion should  pass  in  very  slowly ;  long  rectal  tubes  are  unnecessary  for 
this  purpose.     This  fluid  should  be  given  at  a  temperature  of  about  100°. 

Diet. — The  patient  should  be  put  upon  a  chiefly  nitrogenous  diet. 
Gluten  bread  or  only  the  crust  of  stale  bread  should  be  allowed.  Meats, 
fowl,  fish,  and  eggs  are  all  admissible ;  but  in  the  vegetable  line  only 
those  forms  should  be  used  which  are  practically  free  from  sugar  and 
starchy  elements.  Of  all  articles  of  food,  white  potatoes  are  the  most 
injurious  in  catarrhal  diseases  of  the  intestine;  there  is  nothing  which 
ferments  more  rapidly  or  furnishes  a  better  medium  for  the  growth 
and  increase  of  bacterial  products  than  this  vegetable.  Spinach,  lettuce, 
celery,  and  such  vegetables  are  all  advisable  in  these  eases.  A  little 
well-cooked  rice  may  be  allowed.  String  beans,  when  fresh  and  green, 
can  also  be  given. 

The  effect  of  coffee  and  tea  is  variable ;  in  some  patients  they  have 
no  detrimental  influence,  while  in  others  no  improvement  can  be  obtained 
until  these  beverages  have  been  absolutely  stopped. 

The  milk  diet,  suggested  by  many  writers,  has  not  proved  itself 
beneficial,  because  it  forms  hard,  insoluble  stools  which  irritate  the 
mucous  membrane  of  the  colon  as  they  pass  through,  and  if  there  be 
any  inflammation  at  the  lower  end  of  the  rectum,  it  often  results  in 
faecal  impaction  there  on  account  of  the  pain  which  the  patient  antici- 
pates from  the  stool. 

Stimulating  drinks  and  alcohol  in  all  forms  should  be  interdicted. 
Hot  water  before  each  meal  sometimes  has  a  most  excellent  effect.  Large 
quantities  should  be  advised  in  the  beginning  to  flush  out  the  stomach, 
intestines,  and  kidneys.  Two  or  three  glasses  may  be  taken  before  each 
meal;  a  pinch  of  salt  added  sometimes  makes  it  more  palatable. 


CATARRHAL   DISEASES  OF   THE    RECTU:\I  AXD   SIGMOID       151 

Medicinal.— The  bowels  should  be  regulated  by  mild  laxatives  if 
necessary.  Malt  and  eascara,  taken  upon  going  to  bed,  is  generally 
effective.  Drugs  that  are  preventive  of  fermentation  are  beneficial. 
Great  benefit  will  be  obtained  from  capsules  or  powders  containing 

Salol,  ] 

„  I aa  gr.  X ; 

Fancreatm,  ( 

Boric  acid gr.  v. 

To  be  taken  one  hour  after  meals. 

Beta-naphthol  has  occasionally  seemed  to  act  more  satisfactorily  than 
the  above  combination.  Very  good  results  have  followed  the  internal 
administration  of  ichthyol,  which  is  given  in  the  form  of  enteric  pills 
containing  3  to  5  grains  each.  When  there  is  a  tendency  to  griping  and 
diarrhcea,  as  there  occasionally  is  in  this  condition,  small  doses  of  castor- 
oil,  5  to  10  drops  taken  in  capsules  every  three  or  four  hours,  will  quiet 
this  materially. 

The  local  applications  will  depend  very  largely  upon  the  extent  of 
the  disease.  "Where  the  sigmoidoscope  reveals  the  fact  that  the  inflam- 
matory phenomena  extend  well  up  into  the  colon,  local  applications 
through  the  speculum  will  be  practically  of  little  benefit.  In  such  con- 
ditions it  is  well  to  place  the  patient  in  the  knee-chest  posture,  and  with 
the  long  bougie,  described  above,  introduce  1  to  3  quarts  of  a  2-  to  10-per- 
cent solution  of  acjueous  fluid  extract  of  krameria.  Peroxide  of  h3'dro- 
gen,  10  to  20  per  cent,  extract  of  hydrastis,  1  ounce  to  2  quarts  of  hot 
water,  a  l-to-10,000  solution  of  bichloride  of  mercury,  or  a  l-to-5,000 
solution  of  nitrate  of  silver  may  all  be  used  in  the  same  manner.  The 
krameria,  however,  has  given  the  best  results,  and  generally  under  its 
use  the  condition  rapidly  improves.  This  drug  as  found  ordinarily  in 
the  shops  is  absolutely  useless.  The  preparation  which  is  recommended, 
according  to  a  formula  devised  for  the  author  by  Dr.  Miiller  some  ten 
years  ago,  is  prepared  as  follows :  :    ' 

Macerate  one  pound  of  bark  of  krameria  in  a  long  percolating  tube  for  twenty- 
four  hours.  After  this  a  mixture  of  20  per  cent  glycerin  and  80  per  cent  water 
is  allowed  to  percolate  through  it.  The  percolate  should  be  constantly  stirred  and 
refiltrated  through  the  bark  the  second  time.  The  filtrate  is  then  evaporated  down 
to  one  pound,  thus  obtaining  an  aqueous  fluid  extract  containing  grain  for  grain 
all  the  therapeutic  properties  of  the  bark.  The  preparation  should  be  kept  in  a 
dark  place  and  not  exposed  to  the  air. 

This  can  be  mixed  freely  with  water  in  any  proportion,  and  throws 
down  no  sediment;  it  can  be  introduced  into  the  tenderest  rectum  with- 
out producing  irritation :  it  is  an  astringent,  and  apparently  soothes  pain 


152 


THE  ANUS,   RECTUM,   AND   PELVIC   COLON 


and  reduces  inflammation.    For  irrigation  it  is  used  in  strengths  of  from 
2  to  20  per  cent,  and  for  local  applications  it  may  be  used  pure. 

If  there  is  any  ulceration  within  view  through  the  sigmoidoscope, 
the  parts  should  be  sponged  or  sprayed  with  a  2-per-cent  solution  of 
nitrate  of  silver.  Applications  of  iodine  or  antinosine  are  also  useful 
under  these  circumstances. 

Injections  of  sweet-oil  and  iodoform  have  not  been  satisfactory  in 
my  hands  in  this  form  of  catarrh,  but  occasionally  relief  has  been  given 
in  the  spasmodic  attacks  by  high  injections  of  6  ounces  of  olive-oil,  with 
half  an  ounce  of  glycerin. 

Recently  some  very  good  results  have  been  obtained  from  high  injec- 
tions of  1  or  2  per  cent  ichthyol  in  olive-  or  cod-liver  oil.  Four  to  6 
ounces  are  injected  once  in  two  or  three  days. 

Bitter  tonics,  cod-liver  oil,  hypophosphites,  bone  marrow,  and  such 
products  as  protonuclein  or  organo  serum  should  all  be  tried  along  with 
the  local  treatment  before  resorting  to  surgical  measures;  but,  on  the 
other  hand,  one  should  not  wait  on  these  too  long. 

Atrophic  Catarrh. — This  is  the  most  frequent  type  of  catarrhal  in- 
flammation of  the  rectum,  and  it  is  always  chronic.  It  is  found  fre- 
quently in  people  about  the  age  of  puberty,  and  in  constantly  increasing 
numbers  as  they  progress  in  years.  The  process  may  begin  in  early  life; 
it  consists  in  a  general  atrophy  of  the  mucous  membrane  and  its  glandu- 
lar elements  throughout 
the  rectum  and  sigmoid 
flexure.  It  is  usually  lim- 
ited to  these  parts,  and 
rarely  ascends  as  high  as 
the  descending  colon. 

Pathological  Anatomy. 
— One  observes  upon  ex- 
amining the  mucous  mem- 
brane in  these  cases  an 
irregular,  bosselated,  or 
granular  appearance.  The 
surface  is  dry,  rough,  in- 
elastic, and  without  any 
salient  vegetations.  At- 
tached to  the  surface  here 
and  there  are  small  masses 
of  dry  fscal  material,  and  occasionally  little  islands  of  necrotic  epi- 
thelium or  pseudo-membrane  (Plate  I,  Fig.  2). 

Microscopic  examination  shows  the  epithelium  absent  in  many  places, 
but  always  present  in  the  deeper  portions  of  the  crypts  of  Lieberkiihn. 


Fig.  85. — Atrophic  Catarrhal  Proctitis. 

Specimen  showing  atrophy  and  exfoliation  of  epithelial 

cells  and  decrease  in  intertubular  substance. 


CATARRHAL   DISEASES   OF   THE   RECTUM  AND   SIGMOID       153 

These  follicles  are  generally  atrophied,  the  intertubular  tissue  decreased 
(Fig.  85),  and  their  goblet-cells  are  few  in  number.  The  cylindrical 
epithelium  is  said  to  assume  the  stratified  pavement  type  in  this  dis- 
ease (Quenu,  Hamonic).  This  change  does  not  extend  more  than  1 
or  2  centimeters  above  the  ano-rectal  line;  it  is  confined  to  the  super- 
ficial surface  of  the  membrane,  and  does  not  involve  the  tubules. 

The  connective  tissue  of  the  submucous  coat  is  dense  and  slightly 
thickened;  it  does  not  contain  embryonic  tissue  and  elastic  fibers,  as  in 
the  hypertrophic  form.  The  solitary  follicles  are  often  enlarged  and 
distended.  At  points  there  are  distinct  granulations  and  ulcerations  ac- 
companied with  hypergemia  and  multiplication  of  the  blood-vessels,  but 
there  is  no  alteration  in  the  blood-vessel  walls. 

Etiology. — It  has  been  suggested  that  this  disease  may  be  produced 
by  emanations  from  foul  closets  and  improper  detergent  material.  The 
author  at  one  time  laid  some  stress  upon  these  factors,  but  in  recent 
years  he  has  seen  such  a  large  increase  in  this  type  of  disease  among 
a  class  of  people  in  whom  such  factors  could  not  be  frequent  that  they 
are  no  longer  considered  seriously.  The  fact  that  this  condition  is  so 
frequently  associated  with  obscure  syphilitic  disease,  leads  him  to  sus- 
pect this  in  almost  every  case;  whether  it  be  acquired  or  hereditary, 
vicious  or  innocent,  it  is  a  distinctly  etiological  factor  in  this  type  of 
inflammation.  In  the  majority  of  cases  there  is  a  history  of  chronic  con- 
stipation associated  with  the  habitual  use  of  laxative  pills,  purgatives, 
and  hepatic  stimulants,  all  of  which  contain  some  resinous  cathartic  and 
irritant  to  the  mucous  membrane  of  the  rectum.  In  most  of  them  the 
continuous  use  of  condiments,  and  stimulants  to  the  appetite  and  diges- 
tion, late  dinners  and  midnight  suppers,  associated  with  little  outdoor 
exercise  and  arduous  social  functions,  contribute  to  the  production  of  the 
disease.  Excessive  school  duties,  close,  unventilated  study-rooms,  and 
improper  or  insufficient  food,  all  have  their  influence.  Many  of  those 
who  suffer  from  this  condition  in  early  life  also  suffer  from  a  dry,  catar- 
rhal condition  of  the  nasal  mucous  membrane,  which  seems  to  show  that 
the  rectal  condition  is  a  part  of  a  general  constitutional  tendency. 

This  type  of  catarrh  may  also  result  from  the  practice  of  sodomy,  the 
use  of  irritating  enemata,  and  from  foreign  bodies  in  the  rectum  whether 
introduced  voluntarily  or  accumulated  by  passage  through  the  intestinal 
canal;  it  also  results  by  vascular  or  lymphatic  extension  from  chronic 
inflammation  of  the  pelvic  and  genito-urinary  organs.  Very  frequently 
it  is  associated  with  old  pelvic  cellulitis  and  the  adhesions  that  result 
from  this  condition.  Perirectal  abscesses,  fistulas,  and  hemorrhoids  are 
frequently  associated  with  the  disease,  but  their  etiological  influence  is 
very  doubtful. 

Symptoms. — The  patient  will  complain,  as  a  rule,  of  long-continued 


154  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

constipation.  The  stools  are  dry  and  hard,  coated  more  or  less  with 
muens,  and  sometimes  tinged  with  blood;  there  is  often  severe  pain 
after  them,  and  this  circumstance  leads  to  the  diagnosis  of  fissure  in  ano. 
Heat  and  burning  in  the  region  of  the  sacrum  and  in  the  rectum  are  fre- 
quent symptoms ;  the  sphincters  are  always  more  or  less  spasmodic.  In- 
troduction of  the  finger  or  of  the  speculum  is  often  painful.  Stretching 
apart  of  the  folds  of  the  buttocks  will  produce  cracks  or  minute  fissures 
in  the  muco-cutaneous  tissue  of  the  anus.  These  little  fissures  may  be 
produced  by  the  passage  of  a  hard  fgecal  mass,  and  result  in  burning, 
itching,  and  sometimes  actual  pain.  They  are  very  shallow;  they  occur 
at  any  point  in  the  circumference  regardless  of  the  radial  folds,  and  heal 
rapidly,  only  to  recur  when  the  parts  are  stretched  again. 

Haemorrhoids  are  a  constant  complication  of  this  type  of  the  disease. 
Frequently  these  are  assumed  to  be  the  cause  of  the  disease  instead  of 
the  result,  and  the  patient  is  operated  upon  only  to  be  disappointed  in 
finding  himself  unimproved.  To  the  eye  the  mucous  membrane  is  bright- 
red  and  of  a  shiny  appearance,  with  little  masses  of  inspissated  faeces 
adhering  to  it  here  and  there  (Plate  I,  Fig.  3).  It  does  not  protrude 
itself  into  the  fenestra,  nor  does  it  collapse  over  the  end  of  the  tubu- 
lar speculum,  as  in  the  hypertrophic  form.  The  surface  is  dry  to  the 
touch,  and  adheres  to  the  finger  as  the  latter  is  pushed  upward ;  there  is 
a  general  atony  of  the  walls  of  the  rectum  in  old  cases ;  the  rugae  seem 
almost  obliterated,  and  the  valves  of  Houston  stand  out  more  promi- 
nently than  is  usual.  There  is  nearly  always  marked  dilatation  of  the 
rectal  ampulla  in  these  cases.  Often  when  the  finger  passes  the  internal 
sphincter  it  glides  into  a  widely  distended  cavity,  the  sides  or  top  of 
which  it  can  scarcely  touch.  In  this  pouch  faecal  masses  accumulate  and 
frequently  lie  from  day  to  day  until  they  become  quite  large,  and  some- 
times result  in  faecal  impaction. 

Ulceration  is  more  frequent  in  this  form  of  catarrhal  disease  than  in 
the  hypertrophic.  The  mucous  membrane  of  the  entire  rectum  may  be 
eroded  and  more  or  less  deeply  ulcerated  in  spots  (Plate  I,  Fig.  6).  This 
is  due  to  the  traumatism  produced  by  the  passage  of  dr}^  hard  fseces  over 
an  improperly  lubricated  mucous  membrane  and  subsequent  infection. 
The  resting  of  these  hard  masses  in  one  position  may  interfere  with  the 
circulation  and  produce  ulceration.  Constipation,  flatulence,  and  indi- 
gestion are  always  a  part  of  this  affection;  the  complexion  may  be  sallow, 
and  the  skin  harsh  and  dry;  the  tongue  is  frequently  coated  a  dirty  yel- 
low, and  there  is  a  bad  taste  in  the  mouth  on  rising  in  the  morning;  the 
appetite  is  frequently  impaired,  and  the  patient  loses  flesh;  the  stools  are 
always  hard,  lumpy,  and  coated  slightly  with  mucus,  blood,  or  pus.  Pru- 
ritus is  often  an  annoying  symptom,  and  interferes  with  the  patient's 
rest  at  night. 


CATARRHAL  DISEASES  OF  THE  RECTUM  AND  SIGMOID       155 

Treatment. — This  form  of  inflammation,  being  limited  largely  to  the 
rectum  and  lower  sigmoid,  is  plainly  within  view  through  the  procto- 
scope, and  consequently  is  more  susceptible  to  local  treatment  than  the 
other  forms. 

The  whole  field  afleeted  can  be  observed  and  treated  from  below,  and, 
as  a  matter  of  fact,  no  treatment  from  above  is  likely  to  prove  efficacious 
except  in  so  far  as  it  prevents  irritating  and  infectious  materials  from 
passing  through  the  diseased  area.  Whatever  will  produce  non-irritat- 
ing, soft,  and  easy  stools  will  conduce  to  the  healing  of  these  parts.  It 
will  be  unnecessary  to  continually  flush  the  colon  by  drastic  purges  in 
order  to  keep  the  parts  clean.  This  may  be  accomplished  by  simple  ene- 
mata,  or  more  completely  by  lavage  of  the  sigmoid  flexure  and  rectum 
through  the  ordinary  rectal  irrigator,  and  by  this  means  the  constant 
peristalsis  and  motion  of  the  parts  caused  by  cathartics  will  be  avoided. 

When  there  is  reason  to  suspect  the  possibility  of  syphilitic  infection, 
it  is  well  to  administer  specific  remedies  along  with  the  local  treatment 
for  this  condition.  As  has  been  stated  elsewhere,  the  use  of  mercury  in- 
ternally is  inadvisable  on  account  of  the  peristaltic  action  and  diarrhoea 
which  it  induces.  It  allows  no  rest  to  the  parts.  Inunctions,  mercuric 
baths,  and  the  hypodermic  administration  of  the  drug  are  all  superior 
to  its  internal  administration  in  cases  of  this  kind.  At  the  same  time  a 
certain  amount  of  iodides  should  be  given  if  the  patient's  stomach  does 
not  rebel  against  them. 

If  there  is  no  specific  element  in  the  case,  tonics,  such  as  cod-liver 
oil,  hypophosphites,  and  some  assimilable  form  of  iron  are  always  called 
for.  As  a  rule,  however,  iron  is  objectionable  in  that  it  tends  to  consti- 
pation and  the  production  of  hard,  irritating  stools.  Malt  with  various 
tonic  constituents  is  an  excellent  remedy;  combined  with  the  fluid  ex- 
tract of  cascara,  and  administered  at  bedtime,  it  gives  a  certain  but  easy 
movement  of  the  bowels  on  the  day  following.  This  and  cold  water 
enemata  are  the  chief  remedies  for  regulating  the  bowels  in  this  condi- 
tion; though  occasionally  recourse  must  be  had  to  others,  such  as  small 
doses  of  calomel  and  soda,  podophyllin,  colocynth,  and  saline  waters. 
These  latter,  however,  should  not  be  repeated  frequently. 

The  diet,  while  it  should  be  as  carefully  governed  in  this  condition 
as  in  the  hypertrophic  catarrh,  is  not  necessarily  so  limited.  Starchy 
products  may  be  taken  in  moderation,  and  also  a  few  sweets.  Potatoes, 
however,  for  the  reasons  before  indicated,  are  interdicted.  Coffee  and 
tea  are  both  injurious  in  these  cases,  and  alcohol  is  to  be  avoided.  Pure 
food  in  generous  quantities,  fresh  air,  and  outdoor  exercise,  especially 
horseback  riding,  should  all  be  encouraged. 

Local  Treatment. — For  the  local  treatment  a  great  many  remedies 
are  recommended  in  the  books  upon  rectal  and  general  diseases,  but  argo- 


156  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

nin,  nitrate  of  silver,  ichtlivol,  hydrastis,  and  oil  with  glycerin  are  those 
that  will  be  found  most  useful.  These  remedies  should  be  applied  after 
the  rectum  has  been  thoroughly  emptied  either  by  a  laxative  or  cold-water 
enema ;  they  may  be  introduced  through  the  Wales  bougie,  and  should 
always  be  carried  up  into  the  sigmoid  flexure  as  high  as  the  disease  ex- 
tends. The  strengths  of  the  solutions  are  governed  by  the  condition  of 
the  gut.  When  there  is  an  extremely  dry  condition  of  the  mucous  mem- 
brane, with  tenacious  mucus  and  inspissated  faecal  masses  adherent  to  it, 
the  parts  should  be  wiped  off  with  pledgets  of  cotton,  and  comparatively 
strong  stimulating  applications  made.  In  such  cases  the  cavity  should 
be  swabbed  out  or  sprayed  with  a  2-  to  5-per-cent  solution  of  nitrate  of 
silver.  This  treatment,  however,  if  carried  out  in  the  sigmoid  flexure, 
produces  considerable  griping  and  pain ;  therefore,  when  the  disease  ex- 
tends high  up  the  use  of  argonin  in  solutions  of  5  to  10  per  cent  is  to  be 
preferred.    This  drug  is  applied  as  follows  : 

The  patient  is  placed  in  the  knee-chest  posture,  the  pneumatic  sig- 
moidoscope is  carried  up  well  into  the  sigmoid  flexure,  the  latter  being 
distended  by  pneumatic  pressure;  after  this  the  e3^epiece  of  the  instru- 
ment is  removed,  and  ^  to  1  ounce  of  the  solution  is  poured  into  the  gut 
through  the  tube ;  the  eyepiece  is  then  replaced,  and  the  gut  again  dis- 
tended as  the  tube  is  withdrawn,  leaving  the  solution  well  up  in  the 
sigmoid.  As  soon  as  the  speculum  is  removed,  peristaltic  action  car- 
ries the  drug  downward  and  applies  it  to  all  the  portions  of  the  intestine 
below. 

Irrigation  with  hot  water  stimulates  the  circulation  in  these  condi- 
tions, and  hastens  the  absorption  of  any  inflammatory  products  which 
may  be  present.  It  is  useless,  however,  to  inject  a  pint  or  quart  of 
hot  water  into  the  bowel  for  this  purpose  and  allow  it  to  be  passed 
out  within  a  few  moments.  The  irrigation  should  be  carried  out 
by  means  of  a  rectal  irrigator  (Fig.  83),  and  should  be  kept  up  for 
fifteen  to  twenty  minutes  at  a  time.  The  water  should  flow  very 
slowly,  and  the  temperature  should  be  gradually  increased  until  it 
reaches  115°  F. 

After  the  irrigation,  the  applications  of  argonin  or  nitrate  of  silver 
will  be  more  effectual,  inasmuch  as  the  mucus  and  pus  will  have  been 
washed  away  from  the  parts.  This  treatment  should  be  carried  out  daily 
at  first,  and  afterward  the  periods  may  be  lengthened  gradually  until 
the  applications  are  necessary  only  once  a  week.  Sometimes  where  the 
irrigation  and  stimulating  applications  set  up  irritation  in  the  rectum 
and  sigmoid,  it  is  well  to  inject  into  the  sigmoid  at  bedtime  2  or  3 
ounces  of  a  20-per-cent  solution  of  the  fluid  extract  of  krameria.  These 
methods  of  treatment  frequently  keep  the  bowels  regular  withoiit  any 
laxative  medicines  or  cold-water  enemata.    If  there  is  much  itching  and 


CATARRHAL  DISEASES  OP   THE  RECTUM  AND  SIGMOID       157 

burning,  and  if  the  sl^in  cracks  easily  about  the  margin  of  the  anus,  appli- 
cations of  the  following  mixture  will  give  great  relief: 

^  Acidi  carbolici oj; 

Acidi  salicylici   oss.; 

Glycerini    §j. 

This  should  be  jDainted  over  the  anus  at  bedtime. 

After  this  an  ointment  of  5  per  cent  ichthyol  and  95  per  cent  lanolin 
is  applied.  By  treatment  with  the  Wales  bougie  the  sphincter  is  grad- 
ually but  gently  dilated,  the  mucous  membrane  becomes  softened  under 
the  influence  of  the  ichthyol  and  lanolin,  the  itching  is  relieved  by  the 
carbolic  compound,  and  the  patient's  symptoms  rapidly  improve.  If 
necessary,  a  cold-water  enema  is  given  every  morning  to  move  the  bowels. 
This  may  be  continued  indefinitely.  It  not  only  induces  a  proper  move- 
ment, but  also  reduces  the  congestion  of  liEemorrhoids.  Occasionally 
where  the  fissure-like  cracks  in  the  mucous  membrane  involve  the  ends  of 
the  sensory  nerve,  stretching  under  nitrous-oxide  gas  or  ethyl  chloride 
will  be  necessary.    These  cases,  however,  are  exceedingly  rare. 

iSTothing  except  soft  cotton  or  moistened  tissue  paper  should  be  used 
for  detergent  purposes.  In  this  condition  washes  and  bathing  are  not 
injurious  at  all,  inasmuch  as  they  keep  the  membrane  softened  and  flex- 
ible, and  thus  prevent  to  a  certain  extent  the  cracking.  Sweet-oil  and 
iodoform  have  been  used  a  number  of  times  in  this  condition,  but  expe- 
rience shows  they  are  not  equal  to  the  remedies  described,  and  are  much 
more  expensive.  When  there  are  ulcerations  upon  the  mucous  membrane, 
as  in  Plate  I,  Fig.  6,  an  insufflation  of  antinosine  directly  to  the  ulcer- 
ated spot  is  of  great  benefit.  The  author  has  applied  nitrate  of  silver 
to  these  conditions,  and  has  found  that  the  healing  has  been  slow  and  the 
suppuration  marked.  Under  the  use  of  antinosine  and  iodine  there  is 
no  suppuration  to  speak  of,  and  the  healing  is  exceedingly  rapid.  In 
cases  in  which  there  is  a  marked  posterior  rectocele  care  should  be  taken 
to  see  that  this  pocket  is  well  emptied,  and  that  no  small  fscal  balls  or 
foreign  substances  accumulate  therein. 

In  very  chronic  cases  much  benefit  will  be  derived  from  a  nightly  in- 
jection of  3  ounces  of  olive-oil  and  i  ounce  of  glycerin.  Albolene  with 
1  per  cent  of  carbolic  acid  or  -|  per  cent  of  menthol  seems  to  have  a  sooth- 
ing efl^ect  in  some  cases.  Occasionally  when  the  haemorrhoids  are  marked 
and  so  inflamed  that  local  treatment  of  the  parts  is  irritating  and  pain- 
ful, it  is  necessary  to  operate  upon  these  first  and  treat  the  catarrhal 
condition  afterward. 

With  the  patient  under  auEesthesia  for  the  hemorrhoidal  operation 
the  author  has  sometimes  touched  the  mucous  membrane  at  spots  all 
around  with  the  thermo-cauter}^,  and  has  found  that  it  had  a  remark- 


158  THE   ANUS,   RECTUM,  AND   PELVIC  COLON 

ably  good  inlluoncc  ii})on  the  condition.  As  a  rule,  however,  it  is  better 
not  to  interfere  with  the  luuniorrhoidal  growths  in  this  condition  until 
the  catarrhal  phenomena  have  been  controlled,  and  in  a  large  number  of 
cases  they  will  be  found  to  have  disappeared  along  with  the  catarrhal 
condition. 

Fistulae  and  extensive  ulcerations  occur  in  connection  with  this  dis- 
ease, and  should  be  treated  by  the  methods  laid  down  in  the  chapters 
upon  these  subjects.  The  treatment  of  the  two  conditions  need  not 
interfere  with  each  other,  except  in  those  cases  in  which  the  fistula  is 
dissected  out  and  the  parts  sewed  together.  Here  one  must  wait  until 
the  parts  have  healed.  Under  other  circumstances  the  treatment  of  the 
catarrhal  condition  may  be  continued  immediately  after  operation,  and 
thus  considerable  time  will  be  saved. 

SPECIFIC    CATARRHAL    INFLAMMATIONS 

Of  these  we  have  mentioned  in  our  classification  four  special  vari- 
eties. The  gonorrhoeal  and  syphilitic  types  will  be  treated  of  in  the 
chapter  upon  Venereal  Diseases  of  the  Eectum  and  Sigmoid. 

Dysenteric  Proctitis  and  Sigmoiditis. — In  order  to  understand  the 
effects  of  dysentery  in  the  rectum  and  sigmoid,  it  will  be  necessary  to 
review  that  disease  briefly.  Authorities  differ  as  to  the  distribution  of 
the  lesions  in  dysentery;  all  agree,  however,  that  sooner  or  later  in  every 
type  they  are  found  at  the  lower  end  of  the  intestinal  tract. 

Etiologi/. — Heat,  cold,  excessive  exercise,  improper  diet,  bad  water, 
faulty  drainage,  the  environments  of  army  life  and  that  in  large  elee- 
mosynary institutions,  have  at  times  been  looked  upon  as  causes  of  dysen- 
tery, but  it  is  now  believed  that  the  disease  is  always  the  result  of  infec- 
tion. When  Councilman  and  Lafleur  (Johns  Hopkins  Hospital  Re- 
ports, 1891)  associated  amoeba?  dysenterias  with  this  disease  it  was 
thought  its  etiology  had  been  finally  settled.  Later,  however,  the  bacillus 
of  Shiga  (Centraiblatt  f.  Bakt.  u.  Parasitenk.,  1898,  Nos.  22  and  21) 
was  announced  as  the  only  pathogenic  agent  constantly  found  in  epi- 
demic dysentery  of  Japan;  and  when  Flexner  confirmed  this  observation 
it  seemed  for  a  time  that  the  specific  influence  of  the  amoeba?  had  been 
disproved.  The  arguments  against  the  amoeba?  were :  it  was  found  in 
water;  also  in  other  diseases;  it  was  not  constantly  present  in  epidemic 
dysentery ;  it  could  not  be  isolated  as  a  pure  culture.  Flexner  finally 
concluded  that  the  amoeba?  had  some  pathogenic  influence;  he  held, 
however,  with  Kartulis,  Kruse,  Paschal,  and  Cruikshank  that  it  must 
be  associated  with  other  pathogenic  organisms  in  order  to  produce 
dysentery  (Journal  American  Medical  Association,  January  5,  1901). 
Pathologists  have  sought  diligently  to  establish  the  unity  of  dysentery, 


CATARRHAL  DISEASES  OP  THE   RECTUM  AND   SIGMOID       159 

but  Flexner,  Vaillard,  Vedder,  and  Duval  (Journal  Experimental  Medi- 
cine, 1902,  No.  2),  and  Kruse  (Deutsch.  med.  Wochensch.,  1901,  Nos.  2, 
3,  and  24)  have  each  described  bacilli  dysenteric  differing  from  that  of 
Shiga.  Kruse  describes  that  discovered  by  him  as  "  pseudo  bacillus," 
but  Gay  and  Duval  claim  that  all  these  varieties  belong  to  one  type. 
Admitting  the  latter,  the  fact  that  many  cases  have  been  observed  in 
which  the  bacilli  were  absent  and  the  agglutination  tests  failed,  and  yet 
in  which  the  amoebse  dysenteri^e  were  present,  has  led  to  the  conclusion 
that  this  unity  of  the  disease  can  not  be  established.  In  the  discussion 
in  the  British  Medical  Association  in  1902,  it  was  clearly  proved  that 
there  are  three  types  of  dysentery:  The  catarrhal,  the  amoebic,  and  the 
bacillary.  To  these  may  be  added  a  fourth,  due  to  mixed  infections. 
Councilman  and  Lafleur  applied  the  term  tropical  dysentery  to  those 
due  to  amoebic  infection.  This  term  is  misleading,  for  it  is  now  well 
known  that  amoebic  d^^sentery  also  originates  in  temperate  climates;  the 
author  has  seen  it  in  patients  who  have  never  been  south  of  the  thirty- 
fifth  parallel  of  latitude;  and  in  the  southern  portion  of  the  United 
States  the  disease  occurs  frequently.  Until  recently  it  was  generally 
assumed  that  bacillary  dysentery  was  confined  to  the  warmer  zones. 
Kecent  investigations,  however,  have  proved  that  even  this  type  may 
develop  in  the  colder  zones.  Vedder  and  Duval  {op.  cit.)  have  found 
the  bacilli  in  dysentery  originating  in  the  United  States,  and  more 
recently  Duval  and  Basset  (American  Medicine,  vol.  iv,  page  417),  Wol- 
lenstein,  Lambert,  and  Jones  have  discovered  it  in  the  ordinary  summer 
diarrhoea  of  children  in  and  about  New  York.  Such  wide-spread  preva- 
lence of  the  organism  in  such  clinically  different  cases  seems  to  cast 
some  doubt  upon  its  specific  influence  in  true  dysentery,  especially  when 
we  consider  the  fact  that  Futcher  (Journal  American  Medical  Associa- 
tion, August  24,  1903),  in  his  report  of  119  cases  in  Johns  Hopkins 
Hospital,  says  that  all  showed  the  presence  of  amoebae  dysenterise  and 
none  responded  to  the  bacillary  tests.  In  the  cases  treated  by  the  author 
in  which  the  bacilli  were  found,  amoeba3  were  also  present;  it  was 
impossible,  therefore,  to  decide  which  was  the  etiological  factor.  The 
weight  of  evidence,^  however,  is  in  favor  of  the  specific  influence  of  the 
Shiga  bacillus,  and  clinicians  are  therefore  forced  to  the  conclusion  that 
the  four  types  of  dysentery  mentioned  above  are  established  and  must 
be  dealt  with  accordingly. 

Catarrhal  Dysentery. — The  etiological  factor  in  the  peculiar  dysen- 
tery seen  in  large  eleemosynary  institutions  has  not  yet  been  discovered, 
and  therefore  it  is  placed  in  this  class.  In  the  absence  of  any  specific 
organism  one  must  consider  this  disease  as  nothing  more  than  the  acute 
catarrhal  inflammation  of  the  lower  bowel,  described  in  the  first  para- 
graph of  this  chapter. 


160  THE  ANUS,  RECTUxM,  AND   PELVIC  COLON 

Bacillary  Dysentery. — This  type  of  dysentery  is  due  to  infection  of 
the  mucous  membrane  itself  by  the  Shiga  bacillus  or  one  of  its  proto- 
types. The  source  of  the  bacillus  is  practically  unknown.  It  is  sup- 
posed to  enter  the  intestine  through  food  and  drink,  though  it  has  not 
been  discovered  in  them. 

Symptoms. — The  onset  is  sudden,  sometimes  with  a  chill,  followed 
by  a  rise  in  temperature,  acute  griping  pains  and  burning  in  the 
rectum.  The  stools  are  at  first  semi-formed,  then  liquid,  and  finally 
they  are  composed  of  nothing  but  mucus  and  fresh  blood.  Tenesmus 
is  marked,  emaciation  is  rapid,  nausea  is  frequent,  and  collapse  takes 
place  early  in  the  course  of  the  disease.  The  constitutional  symptoms 
are  due  to  toxins  and  not  to  the  activity  of  the  bacilli  themselves,  for 
it  has  been  proved  by  Lentz  (Handbuch  d.  path.  Microorganismen,  Lie- 
ferung  7,  page  320)  and  Todd  (British  Medical  Journal,  December  5, 
1903)  that  these  may  be  caused  by  the  injection  of  dead  as  well  as  living 
bacilli  into  the  subject.  No  reports  have  been  made  of  proctoscopic  ex- 
aminations in  acute  bacillary  dysentery.  The  necropsies,  however,  show 
that  the  lesions  are  largely  confined  to  the  lower  end  of  the  colon.  The 
infection  is  superficial,  and  rarely  spreads  to  the  peritonseum  or  neigh- 
boring organs.  The  area  of  colon  infected  is  large,  the  ulcers  assume 
irregular  forms  and  bleed  easily.  The  whole  circumference  of  the 
gut  is  involved  in  the  intense  infection,  and  the  mucous  membrane  may 
slough  away  leaving  a  raw,  granulating  surface  over  various  lengths 
of  the  colon.  The  bacilli  are  found  abundantly  in  the  stools  and  in 
the  scrapings  from  the  intestinal  wall,  but  microscopical  examinations 
have  failed  to  demonstrate  their  presence  in  the  outer  layers  of  the 
gut.  The  bases  of  the  ulcers  are  usually  soft,  but  in  severe  cases  they 
become  fibrous  and  show  marked  contraction  on  healing,  thus  indicat- 
ing the  possibility  of  stricture.  The  blood  responds  to  the  agglutina- 
tion test.     Convalescence  is  slow  and  relapses  are  frequent. 

Treatment. — The  experience  of  Buchanan  (British  Medical  Journal, 
February  1,  1900,  vol.  i,  page  800,  and  1903,  vol.  ii,  page  843)  and 
Cruikshank  (Jour.  Amer.  Med.  Assoc,  1901,  vol.  i,  page  5-4)  show  that 
treatment  by  large  doses  of  sulphate  of  magnesium  and  sulphate  of 
soda  give  the  best  results,  especially  if  associated  with  irrigation  of  the 
colon.  Some  prefer  the  use  of  castor-oil,  and  if  taken  early  in  the 
disease  it  is  sometimes  successful.  Normal  saline  solution  and  a  solu- 
tion of  sulphate  of  quinine,  1-1,000,  are  the  irrigants  recommended. 
Opium  in  sufficient  quantities  to  control  tenesmus  and  diarrhoea  is  often 
necessary;  internal  medication  other  than  tonics  is  contraindicated. 
Ipecacuanha  has  long  been  considered  a  sort  of  specific  for  dysentery, 
but  the  latest  authorities  are  almost  unanimous  in  condemning  it. 

The  serum  treatment  of  bacillary  dysentery  is  worthy   of   serious 


CATARRHAL  DISEASES  OF   THE   RECTUM  AND  SIGMOID       161 

consideration.  It  is  based  upon  the  fact,  already  mentioned,  that  the 
constitutional  symptoms  are  due  to  a  toxin  derived  from  the  bacilli  and 
not  to  the  activity  of  the  bacilli  themselves.  To  counteract  this  toxin 
an  antitoxin  is  necessary.  Shiga,  by  progressively  immunizing  horses, 
produced  an  antitoxic  serum  with  which  366  cases  were  treated  in  the 
laboratory  hospital  in  Japan,  with  a  mortality  of  9.7  per  cent.  In  the 
same  epidemic  there  was  a  mortality  of  31.7  per  cent  in  2,736  cases 
treated  without  the  serum  (Public  Health  Eeports,  January  5,  1900). 
Todd  {op.  cit.)  has  made  some  interesting  experiments  with  serum 
obtained  by  a  different  process.  In  animals  this  serum  seems  to  neu- 
tralize virulent  toxin  injected  into  the  blood,  and  if  it  proves  as  effectual 
in  man  we  may  soon  have  as  useful  an  adjuvant  for  the  treatment  of 
bacillary  dysentery  as  we  have  for  diphtheria.  It  will  still  be  neces- 
sary to  use  laxatives  and  irrigations,  however,  in  order  to  rid  the  bowel 
of  the  bacilli  and  prevent  further  toxaemia.  The  diet  should  be  milk, 
animal  broths,  rice,  barley  water,  etc.,  with  a  sufficient  amount  of  stimu- 
lants to  maintain  the  strength  of  the  patient. 

Amoebic  Dysentery. — This  form  of  the  disease  is  due  to  infection 
and  infiltration  of  the  submucosa  by  amoeba  dysenteries;  it  is  much 
more  insidious  in  its  onset  than  the  bacillary.  It  may  appear  as  an 
acute  diarrhoea  with  discharges  of  bloody  mucus  and  more  or  less 
burning  in  the  rectum;  or  it  may  come  on  as  simple  looseness  of  the 
bowels  with  gradually  increasing  stools;  the  patient  may  at  first  have 
only  two  or  three  passages  a  day,  one  of  which  may  be  perfectly  normal, 
while  the  others  are  thin,  watery,  and  contain  much  mucus,  with  or 
without  blood.  In  the  acute  cases  burning  in  the  rectum  and  frequent 
desire  to  defecate,  loss  of  appetite,  and  slight  elevation  of  temperature 
are  generally  observed;  but  severe  constitutional  symptoms  are  mark- 
edly absent;  the  stools  may  number  from  three  to  forty  or  more  a  day; 
the  demand  is  imperative,  but  it  is  rarely  associated  with  excessive  pain 
or  tenesmus.  In  some  cases  emaciation  comes  on  very  early  in  the  dis- 
ease, while  in  others  it  does  not  occur  at  all.  One  of  its  chief  features 
is  its  irregular  course,  consisting  of  intermissions,  relapses,  and  ex- 
acerbations. The  disease  may  last  for  years,  with  varied  periods  of 
quiescence  and  recurrence.  These  quiescent  periods  may  last  for 
months.  The  recurrences  take  place  in  cold  as  well  as  warm  weather, 
but  more  frequently  in  the  latter.  As  Rogers  pointed  out  and  as  the 
writer  has  observed,  the  amoebic  infection  may  exist  in  a  latent  form 
and  even  end  in  death  from  complications  without  noticeable  diarrhoea. 
The  chief  complications  are  extreme  anaemia,  localized  peritonitis,  and, 
above  all,  abscess  of  the  liver. 

The  local  appearance  of  the  parts  as  observed  in  two  acute  cases  was 
as  follows :  The  mucous  membrane  at  the  anus  was  pouting,  bright  red, 
11 


162  THE  ANUS,   RECTUM,   AND   PELVIC  COLON 

and  swollen;  the  folds  were  crdematoiis  and  painful;  the  walls  of  the 
rectum  were  in  close  apposition  with  each  other,  hot  and  tender  to  the 
touch,  bright  red  in  appearance,  and  in  one  ease  there  were  several 
patches  of  pseudo-membrane.  At  this  stage  of  the  disease  no  actual 
ulcerations  were  observed,  but  later  on  they  developed  in  both  cases. 
These  ulcers  were  shallow,  irregularly  oval  in  shape,  elevated  in  the 
center,  and  had  sloping  edges.  The  difference  between  them  and  those 
seen  in  chronic  amoebic  dysentery  is  attributed  to  the  fact  that  these 
cases  were  treated  on  the  basis  of  a  local  infection  from  the  beginning, 
and  the  ama?bc'e  were  destroyed  before  the}'  had  invaded  the  deeper 
layers  of  the  submucosa.  Eogers  states  that  the  lesions  appear  first  as 
small  red  dots,  which  soon  develop  a  yellow  spot  in  the  center,  due  to 
ihe  loss  of  epithelium.  The  writer  has  frecjuently  seen  these  in  chronic 
amcebic  dysentery ;  but  he  did  not  observe  them  in  either  of  the  acute 
cases  examined. 

In  the  chronic  form  the  ulcers  are  irregularly  round,  varying  from 
a  split  pea  to  one  inch  in  diameter.  They  are  usually  situated  upon  the 
summits  of  the  folds  of  the  mucous  membrane,  the  folds  of  Houston 
being  favorite  sites  for  them   (Fig.  85a).     The  long  axis  of  the  ulcer 

is  generally  at  right  angles  to  that 
of  the  gut,  but  when  it  involves  a 
large  area  this  rule  is  reversed.  The 
isolated  ulcers  are  well  defined;  the 
center  is  composed  of  a  yellowish 
mass  raised  above  the  level  of  the 
mucous  membrane;  the  edges  are 
thickened,  prominent,  and  surround- 
ed by  a  dark  red  or  purplish  zone; 
in  the  very  chronic  forms  they  may 
assume  a  trough-like  shape  with 
clear-cut,  overhanging  edges  (Fig. 
86),  which  dip  down  into  the  sub- 
FiG.  S5a.— typicAL  Ll..l;;-   .i  Amcebic     puucosa    and    somctimcs    cross    one 

Dysentery.  ,  ...  ,11, 

another,  producing  a  stellate  ap- 
pearance. The  mucous  membrane  between  the  isolated  ulcers  appears 
to  be  perfectly  healthy.  Eogers,  in  his  numerous  necropsies,  has  shown 
that  the  lesions  are  larger  in  the  caput  coli  and  ascending  colon 
than  elsewhere.  In  the  trough-like  ulcers  the  base  is  hard  and  fibrous, 
and  the  inflammation  may  extend  to  the  peritoneal  layer,  causing 
adhesions.  The  yellow  gelatinous  mass  which  forms  the  center  of 
the  ulcers  is  composed  of  submucosa  infiltrated  with  amoebae  dysen- 
terise.  The  latter  are  more  easily  found  in  the  small  ulcers  than  in  the 
large.     In  severe  cases,  Eogers  has  seen  large  sloughs  composed  of  de- 


CATARRHAL   DISEASES  OF  THE   RECTUM   AND  SIGMOID        163 


tached  slireds  of  mucous  membrane  at  the  site  of  the  ulcer.  These  cases 
were  always  associated  with  amcebic  abscesses  of  the  liver  which  contained 
other  pathogenic  organisms,  showing  that  the  gangrene  was  due  to  a 
mixed  infection.     The  odor  in  these  cases  was  gangrenous  and  fetid, 

which    is    entirely    unlike  

that  in  amcebic  dysen- 
tery. When  the  ulcers  be- 
gin to  heal,  the  yellow  cen- 
ter melts  away,  assumes  a 
grayish  tint,  and  gradually 
disappears,  leaving  a  clean 
granular  base,  somewhat 
indurated,  and  which  con- 
tracts as  it  heals. 

Distribution  of  t.lte  Le- 
sions.— The  author's  ex- 
perience differs  from  that 
of  the  majority  of  observ- 
ers with  regard  to  this 
phase  of  the  disease.  Rog- 
ers, Futcher,  and  others 
state  that  the  caecum,  ap- 
pendix, and  ascending  colon 
are  the  chief  sites  of 
the  lesions.  In  116  cases 
Futcher  rarely  found  them 
in  the  rectum  and  sigmoid. 
Strong  and  others,  how- 
ever, agree  with  the  writer  in  stating  that  these  portions  of  the  intestine 
are  by  no  means  infrequently  affected.  In  the  experience  of  the  author, 
typical  ulcerations  of  the  rectum  and  sigmoid  were  found  in  95  per 
cent  of  the  cases.  In  every  instance  except  one  the  character  of  the 
lesions  was  proved  by  the  demonstration  of  living  motile  amoebae  in  the 
stools  and  scrapings  from  these  ulcers.  Futcher  bases  his  diagnosis 
upon  the  finding  of  amoebae  dysenteric  in  scrapings  from  the  rectal 
walls.  In  a  number  of  instances  observed  the  amoebic  ulcers  decreased 
in  size  and  frequency  from  the  rectum  upward;  in  several  they  entirely 
disappeared  in  the  upper  portion  of  the  sigmoid.  Why  these  experi- 
ences should  differ  so  materially,  it  is  impossible  to  say,  unless  it  be 
due  to  the  fact  that  the  observations  of  the  writer  have  all  been  made 
upon  living  subjects,  while  those  of  the  authors  quoted  were  made  upon 
post-mortem  specimens.  There  is  no  doubt,  however,  that  the  rectum 
and  sigmoid  are  involved  in  a  large  percentage  of  clironic  dysenteries. 


Fig.  86. — Linear  A^-D  Stellate  Ulceration  ox  Hocstox 

Valves  seex  IX  Patiext  with  Amcebic  Dysentery. 

Amoebae  dysenterise  were  present  in  the  rectum  at  the 

time  this  drawing  was  made.     Tracbimonas  intesti- 

nalis  were  also  found  in  the  stools  at  a  later  period. 


164  THE   ANUS,   RECTUM,   AND   PELVIC  COLON 

Diagnosis. — The  diagnostic  test  is  to  find  in  the  stools,  or  in  the 
scrapings  from  the  ulcers,  living  motile  amcehffi  dysenteric.  It  may 
require  several  examinations  hefore  they  can  be  found,  but  vi^hen  once 
seen  the  diagnosis  is  beyond  doubt.  The  methods  of  examination  for 
amoebje  are  detailed  in  works  on  pathology.  The  writer  would  call 
attention,  however,  to  two  facts,  namely :  the  amfebse  can  not  be  found 
easily,  if  at  all,  in  stools  that  have  once  cooled  off  below  70°  F.,  and 
secondly,  the  diagnosis  will  be  nnich  more  positive  if  the  amoebs  are 
observed  in  the  scrapings  from  the  ulcers.  The  specimens  to  be  exam- 
ined should  either  be  kept  in  an  oven  at  the  normal  temperature  of 
the  body,  or  examined  upon  warm  slides  immediately  after  collection. 
No  examination  can  be  considered  diagnostic  unless  it  has  been  made 
in  this  manner. 

Treatment. — This  disease  is  an  infection  and  infiltration  of  the  sub- 
mueosa  by  amcebffi  dysenteric :  there  are  rarely  any  serious  constitu- 
tional numifestations  except  when  due  to  complications.  There  is  no 
indication,  therefore,  for  an  antitoxin  as  in  bacillary  dysentery,  but 
rather  for  a  supporting  treatment  while  the  local  infection  is  being 
eradicated.  As  the  amcebc  are  largely  buried  in  the  tissues,  it  will  be 
impossible  to  destroy  them  by  superficial  washing  or  flushing  of  the  in- 
testinal canal.  These  methods  are  important  to  get  rid  of  those  on  the 
surface,  but  something  must  be  employed  that  will  penetrate  the  tissues 
and  destroy  the  buried  germs  in  order  to  completely  cure  the  disease. 
The  remedies  that  are  toxic  to  amcebc  dysenteric  are  mercuric  chloride, 
silver  nitrate,  solutions  of  quinine,  and  hydrogen  peroxide.  Bichloride 
of  mercury  in  warm  solutions  appears  to  have  no  influence  in  checking 
the  motility  of  amcebc  unless  the  strength  is  so  great  that  it  would  be 
dangerous  to  inject  it  into  the  intestinal  canal.  Silver  nitrate  in  a 
solution  of  .5  per  cent,  if  used  warm,  does  not  destroy  the  amoebge;  in 
solutions  of  3  per  cent  it  seems  to  do  so,  but  in  this  strength  it  is  very 
irritating  to  the  bowel,  and  forms  a  layer  of  silver  albuminate  over  the 
ulcer  which  simply  protects  the  buried  organisms.  Rogers  has  shown 
that  a  solution  of  quinine  sulphate,  1-1,000,  failed  to  destroy  free 
amoebae  after  several  hours'  contact;  a  solution  of  1-500  stopped  their 
movements  in  five  to  fifteen  minutes,  although  a  temporary  stimulating 
effect  was  sometimes  observed.  In  scrapings  from  the  walls  of  amoebic 
abscesses  or  ulcers  the  aniffbae  were  only  destroyed  after  long  soaking 
of  the  tissues  in  solutions  of  1-500  or  even  1-100.  Harris,  of  Atlanta, 
claims  that  quinine  is  not  germicidal  to  amoebc  dysenteric,  but  that 
hydrogen  peroxide  is.  IvTeither  of  these  authors  state  whether  their  ex- 
periments were  made  with  cold  or  warm  solution,  but  as  they  recom- 
mend warm  injections  it  is  to  be  supposed  that  they  uspd  the  same  in 
their  experiments.    Admitting  that  both  quinine  and  hydrogen  peroxide 


CATARRHAL   DISEASES   OF   THE   RECTUM  AND   SIGMOID        165 

are  germicidal  to  the  amceba?,  it  would  be  impossible  to  hold  the  solu- 
tions in  contact  with  the  ulcers  long  enough  for  the  fluid  to  penetrate 
the  tissues  and  kill  the  buried  germs,  for  in  most  patients  the  intestines 
are  very  intolerant  of  the  presence  of  either  drug.  The  fact  that  the 
quinine  and  silver  solutions  fall  to  reach  the  buried  amoebaB  accounts 
for  the  recurrences  of  the  disease  in  patients  who  have  been  treated  with 
them.  The  ideal  treatment  must  therefore  consist  of  some  method  by 
which  this  buried  organism  can  be  reached  and  destroyed  in  situ. 

It  was  observed  that  whenever  the  specimen  stools  or  the  slides  upon 
which  amoebEe  were  being  examined  cooled  below  a  temperature  of 
■70°  F.,  the  motility  of  the  amoebge  was  lost  and  could  not  be  restored. 
This  suggested  that  if  the  temperature  of  the  parts  containing  these 
organisms  could  be  reduced  below  70°  F.,  their  infecting  and  reproduc- 
tive powers  would  be  eliminated.  It  was  therefore  determined  to  treat 
these  cases  by  cold  injections.  At  first  krameria,  ichthyol,  c^uinine,  or 
silver  nitrate  were  introduced  into  the  douches,  but  one  after  another 
was  discarded,  as  it  was  found  that  simple  cold  water  was  just  as 
effectual  as  any  of  the  medicated  solutions  to  rid  the  bowel  of  amoebfe. 
In  some  patients  it  was  necessary  to  use  the  long  rectal  tube  in  order  to 
get  the  fluid  up  in  the  colon,  but  in  the  majority  the  rectal  tip  of  a 
fountain  syringe  was  sufficient.  The  patients  were  placed  in  the  knee- 
chest  posture  and  the  fluid  allowed  to  run  in  very  slowly.  The  amount 
of  water  that  can  be  received  varies ;  some  patients  can  take  only  a  pint 
at  first,  but  by  perseverance  they  learn  to  take  even  two  or  three  quarts ; 
the  time  of  retention  varies  also;  some  can  retain  the  water  for  one-half 
or  three-quarters  of  an  hour,  while  others  are  compelled  to  go  to  the 
toilet  immediately  after  the  injection.  In  the  latter  class  it  is  necessary 
to  repeat  the  injection  two  or  three  times  at  each  sitting  in  order  to 
obtain  the  effects  desired.  The  treatment  is  always  begun  l3y  the  admin- 
istration of  large  doses  of  sulphate  of  magnesium,  and  this  process  is 
repeated  once  every  week  during  the  course  of  treatment.  The  time 
consumed  in  ridding  the  bowel  of  the  amoebae  depends  entirely  upon 
the  tolerance  of  the  intestine  to  cold  water ;  in  those  cases  in  which  large 
amounts  of  very  cold  water  can  be  retained  the  organisms  disappear  in  a 
very  short  time;  while  in  those  who  can  only  retain  small  quantities  for 
short  periods,  several  weeks  are  required.  In  the  acute  cases  seen  the 
amcebge  disappeared  from  the  stools  after  three  days'  treatment  by  the 
cold  injections  and  never  reappeared.  In  the  chronic  cases  the  time 
required  is  longer  and  recurrences  may  take  place.  Where  there  is  ten- 
derness over  the  cfficum  and  hepatic  flexure,  an  ice-bag  is  applied  over 
these  regions  for  two  hours  twice  daily.  When  the  bowel  is  tolerant  of 
hydrogen  peroxide,  5  to  10  per  cent  of  this  remedy  is  introduced  into  the 
water  on  account  of  its  beneficial  effect  on  the  ulcers  and  to  combat  any 


166  THE  ANUS,   RECTUM.  AND   PELVIC  COLON 

mixed  infections  that  may  be  present.  The  water  should  be  used  at  a 
temperature  of  45°  or  less.  In  the  acute  and  subacute  cases  cold  is  grate- 
ful and  soothing  to  the  patient.  In  the  chronic  cases  there  is  less  toler- 
ance of  it. 

The  localized  idcers  in  the  rectum  and  sigmoid  are  treated  every 
other  day  by  local  applications  of  astringent  and  antiseptic  substances; 
tincture  of  iodine  is  one  of  the  best,  and  antinosine  insufflated  upon  the 
spots  is  a  most  satisfactory  method  of  applying  it.  Argyrol  (50  per 
cent)  is  also  effectual.  Silver  nitrate  is  said  to  be  a  specific  for  these 
ulcers,  but  we  have  never  seen  a  case  cured  by  it.  Its  effects  are  too 
superficial  to  reach  the  buried  amoeba\  The  only  internal  medication 
indicated  is  such  as  will  be  found  necessary  to  assist  digestion  and 
maintain  the  strength  of  the  individual  while  undergoing  treatment. 
Opium  suppositories  are  occasionally  necessary  to  quiet  rectal  irrital)ility. 
The  diet  should  be  largely  nitrogenous,  with  fats,  butter,  rice,  and  stale 
or  toasted  bread.  In  the  experience  of  the  author,  this  line  of  treatment 
has  succeeded  almost  invariably,  but  one  can  easily  conceive  of  cases  so 
intolerant  to  cold  water  that  it  will  be  impossible  to  flood  the  caecum 
and  thus  reach  the  seat  of  the  disease.  In  such  cases,  as  Murray  has  well 
stated,  it  will  be  necessary  to  resort  to  some  surgical  means  to  reach  the 
spot  and  treat  the  ulcers.  There  are  two  methods  to  do  this :  the  first 
is  that  of  Weir,  who  makes  a  small  incision  through  the  abdominal  wall 
at  McBurney's  point,  drags  the  ajipendix  through  this  and  sutures  it  to 
the  skin;  after  union  has  taken  })lace  and  the  peritoneal  cavity  is  shut 
off,  the  appendix  is  amputated  and  its  opening  into  the  caecum  is  utilized 
for  the  passage  of  a  small  catheter  through  which  the  cold  water  is 
introduced,  thus  reaching  the  upper  limits  of  the  disease  and  flushing 
the  colon  from  above  downward.  The  second  method  is  by  valvular 
colostomy  as  recommended  by  Gibson  and  described  on  page  191. 
Eecognizing  the  fact,  as  stated  l)y  Eogers,  that  the  appendix  may  be  the 
seat  of  amoebic  infection,  it  would  appear  that  the  method  of  Weir 
should  be  the  choice,  or  at  least  this  organ  should  be  removed  in  valvular 
colostomy.  In  the  cases  that  have  been  reported  as  treated  in  this  way 
sufficient  time  had  not  elapsed  when  they  were  reported  to  warrant  one 
saying  that  the  disease  was  entirely  cured,  but  judging  from  our  ex- 
perience with  cold  water  in  amoebic  infections  of  the  rectum,  there  is 
every  reason  to  believe  that  it  will  be  effectual  in  the  upper  colon. 

Diphtheritic  Proctitis. — Pseudo-mem!)ranes  sometimes  occur  in  the 
rectum  during  the  late  stages  of  exhausting  diseases,  such  as  septicemia, 
Bright's,  tuberculosis,  typhoid  fever,  etc.,  but  true  diphtheria  of  these 
is  practically  unknown.  Should  its  existence  in  the  rectum  be  estab- 
lished by  the  presence  of  Klebs-Loeffler  bacilli  in  the  membranes,  it 
should  be  treated  by  antitoxin  injections  and  local  antiseptic  applications. 


CHAPTEE   V 
CHRONIC  COLITIS,   MUCOUS   COLITIS,   MEMBRANOUS  COLITIS 

The  rectal  specialist  is  so  often  consulted  with  regard  to  chronic 
diarrhoea,  constipation,  and  the  passage  of  mucus  and  membrane,  with 
or  without  pus  and  blood  from  the  rectum,  that  it  is  absolutely  essential 
he  should  know  the  conditions  which  cause  these,  and  be  able  to  manage 
them.  Formerly  such  conditions  were  considered  constitutional  affec- 
tions and  treated  by  the  general  practitioner.  To-day  they  are  consid- 
ered by  the  best  authorities  as  surgical,  and  referred  to  specialists  in  this 
line.  Some  still  maintain  that  they  are  the  result  of  general  constitu- 
tional affections,  such  as  anaemia,  chlorosis,  or  neuroses ;  the  latter  is  a 
very  popular  view,  and  held  by  some  of  the  best  general  practitioners. 

Since  writing  upon  this  subject  in  1888  the  author  has  had  the  oppor- 
tunity, through  the  courtesy  of  his  professional  friends,  to  examine  and 
treat  a  large  number  of  these  cases,  after  long  periods  of  rest  in  bed 
and  treatment  on  the  neurotic  theory  had  proved  unsuccessful,  and 
favorable  results  in  these  cases  have  followed  management  upon  the  basis 
of  a  local  inflammatory  disease. 

Close  investigation  has  led  to  the  conclusion  that  the  three  types  of 
colitis  mentioned  at  the  head  of  this  chapter,  and  described  as  separate 
diseases  in  the  works  upon  general  medicine,  are  practically  one  and  the 
same,  only  in  different  stages  of  development.  The  pathological  changes 
are  always  the  same,  consisting  in  a  hypertrophic  catarrhal  inflammation 
of  the  colon. 

Etiology. — The  causes  of  this  condition  are  the  same  as  those  of 
hypertrophic  proctitis,  and  have  been  enumerated  in  the  preceding  chap- 
ter. The  neurotic  element  has  always  appeared  to  be  an  effect  rather 
than  a  cause,  although,  no  doubt,  chronic  catarrhal  colitis  may  develop 
in  individuals  who  are  already  afflicted  with  some  nervous  condition. 
Under  such  circumstances  it  is  a  complication  rather  than  a  cause  or  a 
result.  If  the  disease  was  a  neurosis,  one  would  find  it  much  more  fre- 
quently in  insane  institutions  and  hospitals  for  nervous  diseases  than 
anywhere  else.  Thompson,  in  an  interesting  article  (New  York  Medical 
News,  1900,  vol.  vi,  p.  849),  takes  this  view  with  regard  to  the  neurotic 

167 


168  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

element.  In  discussing  a  case  lie  says  :  "  Although  he  began  to  develop 
all  the  train  of  nervous  symptoms  above  referred  to,  there  can  be  no 
doubt  that  none  of  them  had  any  primary  relationship  to  his  trouble, 
but  were  purely  secondary.  The  beginning  of  the  disease  was  clearly 
due  to  local  irritation  excited  by  local  causes,  acting  first  on  the  lower  end 
of  the  intestinal  tract,  and  gradually  extending  upward."  He  holds 
that  the  origin  of  the  disease  is  in  the  lower  end  of  the  intestinal  tract, 
either  the  rectum  or  the  sigmoid  flexure,  and  extends  upward  from  that 
point ;  that  the  source  of  irritation  is  generally  hardened  faecal  masses  or 
other  foreign  bodies  that  rest  in  the  diverticuli  of  the  intestine,  and  act  as 
irritants ;  and  that  the  condition  may  be  produced  by  horseback  exercise 
or  bicycle  riding.  Irritation  from  the  outside,  such  as  pressure  by  uterine 
or  ovarian  tumors,  may  also  occasion  the  disease. 

It  is  a  well-known  fact  that  hardened  fsecal  masses  and  foreign  bodies 
may  lie  in  the  intestine  for  long  periods  of  time  and  set  up  much  irrita- 
tion, and  yet  the  patient  may  have  liquid  or  semiliquid  stools  periodically 
without  moving  them.  There  are  certain  other  conditions,  however,  not 
mentioned  in  the  books,  which  occasion  colitis.  They  may  be  called  reflex 
rather  than  active  causes;  yet  when  they  are  removed,  the  symptoms 
disappear  and  the  patients  rapidly  recover.  Among  these  attention  is 
invited  to  three,  which  are  very  frequently  associated  with  so-called 
membranous  and  mucous  colitis.  The  first  of  these  is  inflammatory 
adhesion  of  the  colon  or  sigmoid  flexure  to  the  pelvic  organs  or  walls; 
whether  the  inflammatory  process  which  occasions  the  adhesion  ex- 
tends to  the  mucous  membrane  of  the  rectum,  or  whether  the  irritation 
produced  by  its  being  held  firm  and  immovable  while  the  fsecal  masses 
pass  over  or  rest  upon  it,  is  a  question  which  is  difficult  to  decide ;  but,  as 
a  matter  of  fact,  after  attacks  of  pelvic  or  general  peritonitis,  the  colon 
or  sigmoid  flexure  may  become  adherent  to  some  other  organ  of  the  ab- 
dominal cavity,  the  adhesive  bands  interfere  with  the  functional  motions 
of  the  intestine,  and  result  in  a  localized  catarrhal  inflammation  at  the 
points  opposite  them.  This  may  be  due  to  the  fact  that  the  intestine, 
being  held  immovable  at  this  point,  the  peristaltic  action  of  the  parts 
above  produces  a  temporary  intussusception  through  the  fixed  portion, 
and  thus  by  friction  and  more  or  less  obstruction  the  inflamed  condition 
is  brought  about.  One  of  the  chief  seats  for  such  adhesions  is  in  the 
neighborhood  of  the  left  ovary  and  in  Douglas's  cul-de-sac;  another  seat 
is  in  the  neighborhood  of  the  gall-bladder,  where  the  transverse  colon 
passes  in  close  proximity  to  it,  though  this  adhesion  is  more  rare  than 
that  in  the  pelvis. 

These  pelvic  adhesions  sometimes  hold  the  sigmoid  so  firmly  at- 
tached in  Douglas's  cul-de-sac,  or  behind  the  uterus,  that  it  can  not  rise 
up  into  the  abdominal  cavity  when  distended  with  gas  and  fsecal  mate- 


CHROXIC   COLITIS,  MUCOUS  COLITIS,  MEMBRANOUS  COLITIS    169 

rials.  Constipation  and  ftecal  impaction  are  frequentl}'  the  result  of 
this,  and  are  very  difficult  to  overcome.  Through  this  process  the  faecal 
masses  are  retained  in  the  sigmoid  unduly,  catarrhal  inflammation  is 
established,  and  even  ulceration  may  result. 

The  second  condition,  which  may  be  termed  reflex  in  the  production 
of  colitis,  is  subacute  inflammation  of  the  vermiform  appendix.  It  has 
been  the  author's  experience  to  see  a  number  of  patients  who  had  suf- 
fered from  digestive  symptoms,  constipation,  mucous  and  membranous 
colitis,  with  general  debility  and  nervous  exhaustion,  in  whom  the  colitis 
could  be  temporarily  checked  or  benefited,  and  yet  after  brief  periods  of 
time  it  would  return.  In  5  such  cases  the  conditions  were  associated 
with  more  or  less  tenderness  over  various  portions  of  the  abdomen.  In 
only  two  of  them  was  it  limited  to  the  region  of  the  vermiform  appendix. 

In  one  of  these  cases  very  recently  operated  upon  the  symptoms  were 
all  in  the  pelvis,  and  shooting  do^vn  the  right  leg.  So  much  was  this  the 
case  that  the  author  was  firmly  convinced  that  the  condition  was  one  of 
pelvic  adhesion  that  attached  the  ^sigmoid  flexure  either  to  the  perito- 
naeum of  Douglas's  cul-de-sac  or  to  some  of  the  uterine  appendages. 
This  view  was  not  shared  by  the  gynascologists  who  were  called  in  consul- 
tation, both  of  whom  declared  that  the  condition  was  a  neurosis,  and 
that  there  was  no  local  condition  to  justify  an  operation  in  the  woman's 
case.  The  fact,  however,  that  these  adhesions  produced  just  such  symp- 
toms, and  had  been  relieved  by  breaking  up  the  adhesive  bands  and  re- 
storing the  sigmoid  flexure  to  its  normal  position,  led,  against  the  advice 
of  the  consultants,  to  laparotomy  for  exploratory  and  remedial  purposes. 
It  was  a  surprise  when  the  hand  was  passed  into  the  pelvis  to  find  that 
the  ovarian  adhesions  were  so  slight  that  they  could  not  possibly  have 
caused  the  woman's  pains,  and  that  they  were  not  attached  to  the  sig- 
moid at  all.  On  further  investigation,  however,  it  was  found  that  the 
vermiform  appendix  was  hard,  thickened,  subacutely  inflamed,  and  ad- 
herent to  the  peritonaeum  of  Douglas's  cul-de-sac;  it  passed  directly 
across  the  sigmoid  flexure,  and  thus  prevented  the  latter  from  rising 
up  into  the  abdominal  cavity,  as  it  should  do  normally.  There  was  a 
slight  adhesion  of  the  sigmoid  to  the  anterior  rectal  wall,  which  was 
easily  broken  up.  The  appendix  was  removed,  the  csecum  restored  to 
its  position  on  the  right  side,  and  the  sigmoid  flexure  brought  up  above 
the  brim  of  the  pelvis  and  sutured  to  the  abdominal  wall.  Within  a  few 
days  after  the  operation  the  discharges  of  mucus  decreased,  the  bowels 
became  regular,  and  the  woman's  pain  absolutely  disappeared. 

In  the  other  -i  cases  the  symptoms  were  just  as  marked,  and  finding 
nothing  in  the  rectum  or  sigmoid  flexure  to  account  for  the  irritation, 
it  was  decided  to  perform  exploratory  laparotomy.  The  appendix  was 
found  in  a  state  of  subacute  catarrhal  inflammation  in  3 ;  in  1  it  con- 


170  THE  AXUS,  RECTUM,  AND  PELVIC  COLON 

tained  pus,  and  in  the  fourth  the  organ  was  5  inches  long  and  adherent 
to  the  floor  of  Douglas's  cul-de-sac.  It  was  removed  with  the  happy 
result  that  the  symptoms  in  all  four  cases  disappeared  with  remarkable 
promptness.  The  reflex  influences,  therefore,  of  subacute  appendicitis 
in  the  production  of  mucous  and  membranous  colitis  is  well  worthy  of 
further  study. 

In  a  recent  acute  case  of  catarrhal  appendicitis,  in  which  the  appen- 
dix became  adherent  to  the  posterior  abdominal  wall  right  over  the  spinal 
vertebra,  symptoms  of  acute  colitis  and  passages  of  mucus  developed 
within  five  days  from  the  original  attack,  and  receded  just  as  promptly 
upon  the  removal  of  the  inflamed  organ.  Such  cases  will  certainly  have 
their  bearing  in  the  search  for  a  cause  in  any  obscure  case  of  mucous  or 
membranous  colitis. 

Another  condition,  suggested  as  a  cause  of  colitis,  is  floating  kidney. 
How  often  this  condition  influences  the  inflammation  of  the  colon,  and 
whether  it  has  any  initial  exciting  effect  or  not,  is  impossible  to  state. 
The  facts  from  personal  experience  are  limited  to  a  few  cases,  and  to  only 
two  operations  for  the  relief  of  the  same.  In  4  cases  of  chronic  mucous 
and  membranous  colitis  the  coexistence  of  movable  kidney  upon  the  right 
side  has  been  observed.  As  these  kidneys  did  not  seem  to  be  attached 
to  the  intestine  in  any  way,  it  at  first  seemed  improbable  that  they  could 
act  as  exciting  causes  of  the  disease.  Finding,  however,  cases  in  which 
no  other  cause  could  be  ascertained,  in  which  the  kidney  was  more  than 
ordinarily  mobile,  and  therefore  demanded  restoration  and  fixation  on  its 
own  account,  it  was  decided  to  make  the  experiment  and  to  observe  its 
influence  upon  the  intestinal  condition.  At  the  time  of  the  operation 
the  woman  had  been  treated  for  several  weeks  by  local  applications  with 
more  or  less  unsatisfactory  results  with  regard  to  the  passages  of  mucus 
and  membrane  with  the  stool.  She  was  operated  upon  on  October  24, 
1900,  and  after  the  incision  was  made  and  the  kidney  exposed,  the  fol- 
lowing state  of  affairs  was  observed:  As  the  woman  lay  upon  her  side  and 
breathed  deeply  under  the  influence  of  ether  anaesthesia,  the  kidney 
moved  at  least  3  inches  with  every  respiration ;  upon  inspiration  it  shot 
downward  with  considerable  force  and  slid  along  the  posterior  surface 
of  the  colon  for  about  2J  inches,  and  on  expiration  it  shot  upward  again, 
thus  repeating  this  frictional  action  upon  the  intestine.  It  seemed  clear 
that  such  traumatism  would  have  an  irritating  effect  upon  the  bowel ;  in 
the  kidney  it  undoubtedly  produced  congestion,  hypertrophy,  and  gen- 
eral thickening,  the  organ  being  almost  twice  its  normal  size,  and  yet 
without  any  evidence  of  interstitial  or  cortical  disease.  The  capsule  was 
split,  the  body  of  the  kidney  sutured  to  the  fascia  of  the  muscles  as  well 
as  the  two  lips  of  the  incision  in  the  capsule,  and  the  wound  closed  her- 
metically.    Xot  a  single  complication  or  bad  symptom  followed,  and 


CHRONIC  COLITIS,  MUCOUS  COLITIS,  MEMBRANOUS  COLITIS    171 

within  one  week  from  the  time  of  operation  the  mucous  discharges  abso- 
lutely ceased,  and  there  has  not  been  a  return  of  the  same  up  to  the 
present  date,  although  the  patient  still  sutfers  pain  in  the  region  of  the 
kidney.  i\.  few  local  applications  were  made  to  the  congested  mucous 
membrane  in  the  rectum  and  the  sigmoid  afterwards,  but  had  nothing 
whatever  been  done  to  the  lining  membrane  of  the  intestine,  it  is  be- 
lieved that  the  colitis  would  have  been  cured  by  the  removal  of  this  con- 
stant irritation.  One  other  case  of  this  kind  has  been  seen  since  writing 
the  above,  in  which  Dr.  Wyeth,  on  the  author's  advice,  anchored  a  float- 
ing kidney  and  relieved  the  membranous  colitis  it  caused. 

Effort  has  been  made  to  find  some  facts  with  regard  to  this  feature 
of  the  disease,  but  literature  seems  to  furnish  nothing.  This  experience, 
however,  may  lead  in  time  to  the  relief  of  a  certain  class  of  cases  which 
have  heretofore  been  signally  intractable. 

The  occurrence  of  albuminuria  and  hgematuria  in  connection  with 
colitis  has  been  observed  by  many  practitioners.  Thompson  refers  these 
conditions  to  the  absorption  of  colon  bacilli  into  the  blood  through  the 
abraded  mucous  membrane  of  the  colon.  May  they  not  be  due  to  the 
inflammation  produced  in  the  kidney  by  its  mobility? 

In  connection  with  these  extra  intestinal  causes  of  colitis,  attention 
may  be  called  to  the  subject  of  abdominal  aneurisms.  In  6  cases 
observed  by  the  author  and  his  associate,  Dr.  Wellbrock,  intractable 
mucous  colitis  has  existed  in  connection  with  aneurisms  of  the  aorta 
upon  the  level  of  the  transverse  colon.  All  of  these  patients  have  suf- 
fered from  pain  just  above  the  umbilicus,  constipation,  flatulence,  and 
reflex  digestive  disturbances.  The  crises  ordinarily  preceding  the  pas- 
sages of  mucus  were  absent  in  a  large  measure,  and  the  rectum  and 
sigmoid  were  less  affected  by  hypertrophic  catarrh  than  is  usually  the 
case. 

It  seems  that  the  undue  pressure  of  the  aneurism  upon  the  transverse 
colon  and  its  interference  with  the  solar  j)lexus  may  jjossibly  have  some- 
thing to  do  in  the  causation  of  colitis. 

Pathology. — The  fact  that  this  is  not  a  fatal  disease  accounts  for  the 
paucity  of  knowledge  with  regard  to  its  pathological  anatomy.  Most  of 
our  information  has  to  be  draAvn  from  the  examination  of  the  so-called 
membranes  themselves,  assisted  occasionally  by  post-mortem  examina- 
tion of  patients  who  have  suffered  from  this  condition,  and  yet  died  from 
some  other  cause.  As  these  other  causes  are  generally  exhaustive  dis- 
eases, such  as  nephritis,  diabetes,  pneumonia,  and  sepsis,  it  is  difficult  to 
determine  their  exact  influence  upon  the  chronic  condition  of  the  intes- 
tine, for  it  is  well  known  that  a  certain  kind  of  pseudo-membrane  may 
be  developed  in  the  colon  during  the  course  of  any  one  of  these  condi- 
tions.   The  membranes  discharged  are  generally  flakes,  tape-like  or  some- 


172  THE   ANUS,   RECTUM,  AND   PELVIC  COLON 

times  tubular,  that  roproseut  the  caliber  of  the  intestinal  canal.  Some- 
times the  tubes  or  tape-like  masses  are  very  extensive,  measuring  2  or  3 
feet;  generally,  however,  thev  are  only  a  few  inches  long.  They  are  com- 
posed of  a  laminated  albu}ninous  material,  structureless  and  devoid  of 
fiber,  and  enclose  in  their  laminse  small  feecal  masses,  numerous  bacteria, 
epithelial  cells  that  have  undergone  fatty  degeneration,  crystals  of  cho- 
lesterin  and  phosphates,  a  certain  quantity  of  pus  and  leucocytes,  and 
sometimes  the  whole  ejjitlielial  lining  of  the  mucous  follicles.  These 
shreds  or  tubes  may  be  very  thin  or  sometimes  nearly  ^  of  an  inch  thick, 
quite  firm  in  parts,  but  shading  off  into  a  tenacious  glairy  mucus,  which 
clearly  indicates  their  nature.  They  are,  undoubtedly,  formed  first  by  the 
secretion  of  this  glairy  jnucus  from  the  glands,  which  becomes  coagulated 
in  layers,  the  foreign  substances  and  excoriated  epithelium  being  caught 
in  these  laminae  as  they  are  successively  formed.  Under  the  microscope 
these  membranes  appear  structureless  and  transparent.  "  The  inner 
surface  of  the  membrane  appears  to  be  reticulated,  and  presents  depres- 
sions or  perforations  which  correspond  to  the  mouths  of  Lieberkiihn  fol- 
licles." Epithelial  cells  are  occasionally  grouped  around  these  openings, 
showing  that  the  lining  of  the  follicle  has  been  cast  off  and  become  in- 
corporated in  the  membrane.  Sometimes  these  are  larger  than  the  nor- 
mal follicles. 

The  muscular  walls  are  generally  thin  and  atrophied.  The  veins  are 
often  dilated.  At  certain  spots  or  areas  there  are  congestions  and  ex- 
coriations of  the  mucous  membrane ;  the  latter  are  bright-red  in  color 
and  present  the  appearance  of  shallow  ulceration.  The  glandular  and 
submucous  la3'ers  of  the  intestine  are  hypertrophied,  distended  with 
mucus,  and  the  epithelial  cells  appear  to  be  undergoing  fatty  degenera- 
tion. There  is  no  diminution  in  the  caliber  of  the  gut,  but  throughout 
its  extent  there  is  an  hypertrophy  of  the  follicles  and  glandular  layer. 
The  fact  that  the  membrane  is  very  rarely  found  post  mortem  shows  that 
it  is  not  retained  in  the  intestine  for  any  length  of  time  after  its  forma- 
tion. When  it  has  been  found,  it  has  been  confined  to  a  limited  area,  was 
very  easily  detached,  and  ulceration  has  been  very- rarely  seen  beneath  it. 
The  question,  however,  which  is  of  great  interest  in  regard  to  these  condi- 
tions is  the  fact  that  the  passage  of  this  mucus  should  be  preceded  always 
with  such  severe  tormina  and  griping  pains  and  yet  be  unaccompanied,  so 
far  as  post-mortem  examination  shows,  by  any  severe  lesion  in  the  wall 
of  the  gut.  There  is  no  reason  why  a  simple  increase  in  the  secretion  of 
mucus  and  the  passage  of  an  unirritating  soft  mass  of  membrane  should 
be  preceded  or  accompanied  with  severe  pain.  These  masses  are  no 
larger,  no  firmer,  no  more  adherent,  and  no  more  irritating  than  the 
ordinary  faecal  mass.  If  it  is  true,  as  the  pathologists  tell  us,  that  there 
is  no  ulceration  nor  particularly  active  inflammation  at  the  points  upon 


CHRONIC   COLITIS,  MUCOUS   COLITIS,  MEMBRANOUS   COLITIS    173 

Trhich  these  membranes  are  formed,  it  seems  impossible  to  account  for 
the  pain  through  any  inflammatory  process.  Thompson  states  that  this 
condition  is  probably  due  to  some  particular  bacteria,  which  may  cause 
the  pain.  If  such  was  the  ease,  some  form  of  bacterial  organism  would 
have  been  found  more  or  less  constantly  present  in  the  discharges  of 
membrane  and  mucus  which  have  been  so  carefully  examined  by  patholo- 
gists in  the  last  few  years.  The  only  explanation  of  these  pains  that 
seems  practical  lies  in  adhesions,  temporary  volvulus  or  intussusception. 
The  fact  that  the  faecal  passage  sometimes  precedes  the  passage  of  mucus 
does  not  contraindicate  these  conditions;  it  only  signifies  that  the  peri- 
staltic action  of  the  gut  below  the  intussuscepted  portion  carries  whatever 
fsecal  matter  there  is  in  that  part  of  the  bowel  downward,  and  produces  a 
movement  without  giving  relief.  The  irritation  produced  in  the  mucous 
membrane  b}^  intussusception  or  volvulus  may  cause  a  hyperemia  and 
localized  inflammation  with  increased  secretion  of  mucus,  which,  being 
retained,  becomes  thick,  tenacious,  and  membranous.  When  the  intus- 
susception relaxes,  or  the  volvulus  untwists,  this  mucus  or  membrane  is 
passed  rapidh'  downward  and  out  through  the  rectum.  The  patient  gen- 
erally attributes  his  relief  to  the  passage  of  mucus,  but  it  seems  more 
rational  to  ascribe  the  relief  to  the  relaxation  of  spasm  in  the  intestine 
at  the  point  of  constriction. 

The  mucous  membrane  of  the  rectum  and  sigmoid  flexure  in  colitis  is 
always  congested,  sometimes  slightly  ulcerated,  thickened,  and  secretes 
more  or  less  mucus.  The  author  had  under  his  care  a  physician  who  had 
suffered  from  this  condition  for  a  long  period;  the  pseudo-membrane  in 
his  ease  was  seen  frequently  through  the  sigmoidoscope  attached  to  the 
mucous  membrane  of  the  sigmoid  flexure,  and  was  wiped  off  with  pledgets 
of  cotton,  a  part  of  it  being  membranous  and  the  rest  gelatinous.  There 
was  undoubtedly  a  prolapse  or  intussusception  of  this  portion  of  the  in- 
testine into  the  upper  rectum  in  his  case,  and  when  he  suffered  from 
his  acute  attacks,  if  a  long  Wales  bougie  was  passed  sufficiently  high  and 
water  injected  to  distend  the  sigmoid,  the  tormina  ceased,  and  his  pains 
were  relieved ;  moreover,  if  these  bougies  were  passed  regularly,  almost 
regardless  of  what  medication  was  thrown  in,  the  attacks  could  be 
almost  entirely  averted.  This  case  and  several  similar  ones  have  led  to 
the  conclusion  that  this  intussusception  is  the  principal  cause  of  pain. 

Symptoms. — The  disease  generally  occurs  between  the  ages  of  twenty 
and  flfty.  Some  cases  have  been  observed  under  ten  years  of  age,  and 
others  in  those  over  fifty,  but  these  are  exceptional.  It  occurs  in  thin, 
anaemic,  hypochondriacal  individuals,  as  well  as  in  the  well-fed,  rotund, 
and  plethoric.  The  s3^mptoms  are  chronic  intestinal  indigestion  with 
flatulence,  capricious  appetite,  and  a  tendency  to  melancholia  or  mental 
depression. 


174  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

Constipation  is  the  rule,  the  faecal  mass  often  being  in  little,  round, 
hard  balls,  and  coated  with  mucus ;  though  this  condition  may  alternate 
with  diarrhoea.  The  diarrhoea  is  due  to  the  irritation  produced  by  the 
lodgment  of  small,  hard  masses  in  the  saccules  or  diverticuli  of  the  in- 
testine. The  fluid  faeces  produced  by  this  cause  or  by  cathartics  pass  over 
or  around  these  masses  and  leave  them  in  situ  to  continue  the  irritation. 
The  patients  are  generally  sensitive  to  cold,  attributing  this  condition  to 
imperfect  circulation;  the  tongue  is  slightly  furred  with  a  whitish  coat, 
and  the  abdomen  is  generally  more  or  less  distended  with  gas.  White 
states  that  these  patients  sometimes  have  cystitis  and  pass  mucus  with 
the  urine.  He  quotes  Da  Costa  as  saying  that  they  are  frequently  the 
subjects  of  boils. 

The  mental  depression  and  intestinal  symptoms,  while  more  or  less 
present  at  all  times,  have  periods  of  exacerbation  in  which  there  is  abso- 
lute lack  of  appetite,  great  distention  with  gas,  griping  abdominal  pains, 
and  increased  constipation.  After  hours  or  days  of  suffering  in  this  man- 
ner a  mass  of  membrane  or  mucus  is  discharged  from  the  bowel  and  the 
griping  ceases,  but  the  pain  aiid  soreness  remain  for  several  days.  In 
severe  cases  these  passages  of  mucus  and  membrane  may  continue  daily 
for  a  long  time.  Ordinarily  they  are  not  mixed  with  blood,  but  some- 
times bright  blood  passes  with  the  membrane.  White  reports  a  case  in 
which  this  condition  continued  for  several  weeks;  the  patient  was  so 
weakened  that  he  gradually  sank  and  died.  The  author  has  seen  1  case 
in  which  ^  a  pint  of  this  mucus  was  discharged  every  day  for  a  like 
period,  but  there  was  no  blood ;  she  had  very  little  griping  or  pain  ex- 
cept at  periods  two  or  three  days  apart.  In  other  cases  in  which  the 
discharge  of  mucus  and  membrane  was  very  limited,  the  pains  and  ex- 
haustion have  been  very  great.  This  exhaustion  after  the  passage  of  the 
mucus  and  membrane  is  one  of  the  typical  symptoms  of  the  disease ;  the 
patients  are  utterly  collapsed,  sometimes  iniable  to  sit  up  until  hours 
after  the  stool;  they  gradually  lose  strength  and  color,  and  become  sal- 
low and  depressed,  with  forebodings  and  fears.  Their  natures  are  greatly 
changed;  this  is  probably  due  to  the  fact  that  they  suppose  their  ailment 
to  be  of  a  much  more  serious  nature  than  the  physicians  deem  it  to  be. 
Authors  have  laid  stress  upon  the  existence  of  urates  and  uric  acid  in  the 
urine  as  indicating  a  rheumatic  or  gouty  origin  of  the  disease;  this  is 
believed  to  be  erroneous. 

There  is  no  relationship  between  eating  and  the  periods  of  pain  and 
griping;  sometimes  these  occur  just  before  taking  food,  sometimes  im- 
mediately afterward,  and  sometimes  at  remote  periods  from  it.  Insom- 
nia is  quite  frequent;  whether  it  is  due  to  the  disease  itself,  to  the  pain,  or 
to  the  mental  anxiety  concerning  it,  is  a  question  very  difficult  to  answer. 
A  confused  state  of  the  intellect  is  not  infrequently  present  and  due  prob- 


CHRONIC  COLITIS,  MUCOUS  COLITIS,  MEMBRANOUS  COLITIS    175 

ably  to  auto-intoxication,  anxiety,  and  brooding.  The  symptoms  may  re- 
mit and  the  mucus  cease  to  be  discharged;  then  they  recur  with  increased 
virulence,  and  continue  for  varying  periods,  to  disappear  and  recur  time 
after  time.  Only  those  cases  can  be  said  to  be  positively  cured  which  are 
proved  to  have  been  due  to  some  reflex  or  local  cause  which  has  been 
absolutely  removed;  and  even  in  cases  where  the  appendix  has  been  at 
fault  and  has  been  removed,  there  have  been  occasipnal  mild  recurrences 
of  the  disease.  As  is  stated  by  Glasgow  (Journal  of  the  American  Medi- 
cal Association,  1901),  it  is  essentially  a  chronic  disease,  very  seldom 
fatal,  but  of  great  annoyance  to  its  victims. 

Treatment. — From  what  has  been  stated  in  the  preceding  pages,  one 
can  readily  understand  that  there  is  a  very  great  diversity  of  opinion  with 
regard  to  the  treatment  of  this  condition.  By  those  who  hold  that  it  is 
simply  a  neurosis,  nothing  more  is  advised  than  general  tonic  and  seda- 
tive treatment  directed  to  the  nervous  system  or  the  mental  condition. 
Change  of  residence,  travel,  baths,  amusements,  nerve  tonics,  electricity, 
etc.,  compose  the  lines  of  treatment  which  are  laid  down  by  those  who 
adhere  to  this  pathology.  To  those  who  believe  that  it  is  simply  a  ques- 
tion of  chronic  constipation,  some  method  of  emptying  the  bowel,  and 
keeping  it  so,  associated  with  those  means  which  go  to  restore  the  nerv- 
ous and  physical  tone  of  the  individual,  are  all  that  is  necessary.  The 
length  of  time,  however,  required  for  the  treatment  of  these  conditions 
by  the  means  and  methods  of  these  two  schools,  and  the  numerous  fail- 
ures of  such  treatment  to  improve  the  condition  even  temporarily,  speak 
volumes  against  the  correctness  of  any  such  theories.  The  etiology 
which  has  been  advanced  in  the  preceding  pages  differs  so  materially 
from  these  that  it  involves  an  entirely  different  line  of  treatment.  If  this 
condition  is  due  to  intussusception,  adhesions,  reflex  influences,  such  as 
appendicitis,  floating  kidney,  enteroptosis,  or  malpositions  of  the  repro- 
ductive organs  in  women,  the  treatment  consists  in  determining  as  far  as 
possible  which  one  of  these  conditions  is  responsible,  and  remedying  that 
if  feasible.  Nearly  all  the  authors  who  write  upon  this  subject  agree  that 
there  is  a  congestion  or  catarrhal  hyperaemia  of  the  mucous  membrane 
associated  with  swelling  of  the  glandular  and  submucous  layer  at  the 
points  upon  which  these  membranes  or  mucous  shreds  have  been  found. 
Those  who  have  examined  the  rectum  and  sigmoid  have  verified  the  au- 
thor's observations  of  the  fact  that  there  always  exists  a  certain  amount 
of  hypertrophy  and  hyperplasia  in  the  mucous  membrane  of  these  or- 
gans ;  whether  this  condition  is  primary  or  secondary  to  the  membranous 
colitis  it  is  very  difficult  to  say,  though  the  latter  view  seems  most  tena- 
ble, because  the  rectum  and  sigmoid  may  be  restored  frequently  to  their 
normal  condition  by  persistent  and  well-directed  local  treatment,  and  yet 
the  condition  will  recur,  unless  the  colitis  above  has  been  cured  at  the 


176  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

same  time.  Glasgow  {loc.  cit.)  states  that  while  a  large  number  of 
these  cases  are  due  to  appendiceal  inflammation,  they  may  be  treated  by 
therapeutic  measures  and  the  colitis  cured.  He  advises  the  use  of  ich- 
thyol  internally  in  3-  to  5-grain  doses  three  times  a  day.  The  author  had 
used  this  remedy  in  connection  with  3  of  these  cases  for  a  period  of 
about  one  year  previous  to  the  publication  of  Glasgow's  paper;  the 
drug  is  not  a  specific,  but  it  is  a  useful  adjuvant  to  other  lines  of 
treatment.  So  far  as  the  appendix  is  concerned,  the  radical  removal 
of  this  appendage  whenever  and  wherever  there  is  any  evidence  of  in- 
flammation or  adhesion  about  it  is  advisable.  Medical  treatment  is  use- 
ful for  the  time  being,  but  its  results  are  not  permanent.  A  catarrhal 
appendix  with  just  a  little  bit  of  tenderness,  no  temperature,  and  slight 
elevation  of  the  pulse,  is  a  dangerous  appendage.  The  part  does  not 
drain  well,  is  likely  to  become  infected  at  any  time,  and  keeps  up  reflexes 
sometimes,  such  as  membranous  or  mucous  colitis  and  functional  dis- 
orders of  the  digestion,  for  years.  Such  appendices  should  be  removed 
at  once,  and  in  the  majority  of  instances  the  melancholic,  anaemic,  and 
dyspeptic  patients,  who  are  supposed  to  be  the  victims  of  neurotic  co- 
litis, will  immediately  begin  to  improve. 

The  influence  of  floating  kidney  upon  membranous  colitis  is  a  matter 
upon  which  an  expression  of  very  positive  opinion  is  not  at  present  ad- 
visable. In  a  series  of  12  cases  published  by  Dr.  Einhorn,  in  all  of  which 
there  were  digestive  troubles  and  membranous  colitis,  8  of  them  suffered 
also  from  floating  kidney  upon  the  right  side.  In  the  author's  observa- 
tions 6  cases  of  membranous  colitis  have  been  afflicted  with  very  mobile 
right  kidneys.  The  amount  of  mobility  in  the  kidney  does  not  seem  to 
be  in  proportion  to  the  irritation  which  it  produces.  Those  kidneys 
which  float  loosely  around  in  the  abdomen,  sometimes  descending  almost 
to  the  pelvis,  seldom  give  their  possessors  very  much  annoyance ;  whereas 
the  kidney  which  slides  up  and  down  between  the  posterior  abdominal 
wall  and  the  ascending  colon,  moving  some  3  or  4  inches  downward  with 
every  inspiration,  and  upward  on  expiration,  have  been  the  most  annoy- 
ing form  of  this  condition,  and  it  is  the  only  form  in  which  there  was  any 
marked  degree  of  membranous  colitis. 

It  is  not  proposed  to  describe  here  the  methods  of  removal  of  appen- 
dices or  of  fixation  of  floating  kidneys ;  but  it  is  suggested  that  when  no 
other  cause  for  colitis  can  be  determined,  and  when  there  is  a  positive 
diagnosis  of  either  one  of  these  conditions,  surgical  intervention  may, 
and  probably  will,  result  in  the  relief  of  the  intestinal  symptoms.  Opera- 
tive measures  should  be  preceded  by  appropriate  therapeutic  treatment, 
but  it  is  not  believed  that  these  remedies  should  be  persevered  in  for  in- 
definite periods  unless  some  improvement  in  the  symptoms  is  observed. 

The  therapeutic  measures  advised  are :  First,  the  absolute  cleansing 


CHRONIC  COLITIS,  MUCOUS  COLITIS,  MEMBRANOUS  COLITIS    177 

out  of  the  intestinal  canal.  The  fact  that  saline  laxatives  produce  large 
and  copious  watery  defecations  does  not  by  any  means  prove  that  the  in- 
testines have  been  thoroughly  cleansed ;  one  may  be  more  confident  of  a 
proper  cleansing  of  the  intestinal  canal  when  the  patient  has  moderately 
soft,  smooth,  well-formed  fscal  passages.  Fluid  movements  easily  pass 
over  hardened  faecal  balls  retained  in  the  diverticuli  of  the  intestinal 
wall,  and  these  balls  may  be  left  there  for  weeks  and  months  to  act  as 
constant  irritants,  while  the  patients  are  daily  having  semifluid  move- 
ments from  the  use  of  saline  laxatives.  Wylie  has  suggested  the  use  of 
equal  parts  of  glycerin  and  castor-oil  as  a  laxative  in  these  cases,  giving 
a  tablespoonful  of  each  three  times  a  day,  and  continuing  this  for  two 
or  three  weeks ;  he  says  that  so  far  from  its  producing  diarrhoea,  it  only 
keeps  up  a  smooth,  easy  movement,  sometimes  semifluid,  and  is  the  most 
successful  means  to  remove  the  hardened  f^cal  masses  which  accumulate 
and  lodge  in  the  folds  of  the  colon;  this  combination  has  been  used  by 
the  author  in  varied  proportions,  but  never  so  protractedly  as  Wylie  rec- 
ommends. The  daily  administration  of  a  moderate  dose  of  malt  and 
eascara  acts  practically  in  the  same  manner.  This,  with  massage  of  the 
colon  and  lavage  through  the  long  rectal  tube,  has  succeeded  generally 
in  the  removal  of  all  these  accumulations.  The  use  of  a  cannon-ball 
weighing  about  5  or  6  pounds,  and  covered  with  chamois  skin,  is  very 
advantageous  for  massage;  this  is  used  by  the  patient  every  morning; 
beginning  at  the  caecum,  it  is  rolled  upward  over  the  ascending  colon, 
across  the  transverse,  and  downward  over  the  descending  colon  time  after 
time.     It  acts  mechanically,  and  also  by  stimulating  peristaltic  action. 

At  night,  before  the  patient  retires,  it  is  a  good  plan  to  inject  through 
the  long  bougie,  or,  if  this  is  impossible,  by  slow  instillation  through  a 
fountain  syringe,  a  mixture  of  cotton-seed  or  sweet-oil  and  glycerin  into 
the  sigmoid  flexure;  the  quantity  of  this  to  be  used  depends  upon  the 
ability  of  the  patient  to  retain  it;  some  take  only  4  or  5  ounces,  while 
others  retain  1  to  2  pints.  This  should  be  administered  in  the  knee- 
chest  posture,  and  injected  very  slowly  in  order  that  it  may  find  its  way 
as  high  as  possible.  The  patient  should  lie  with  his  hips  elevated  and 
his  head  low  down  for  half  an  hour  after  the  injection  is  given,  and  if 
possible  he  should  retain  the  mixture  all  night.  In  the  morning  his  bow- 
els should  be  moved  by  a  cold-water  enema,  if  necessary,  and  a  regular 
time  should  be  established  for  this  procedure.  After  this  1  pint  of  a  5- 
to  10-per-cent  solution  of  the  aqueous  fluid  extract  of  krameria  should 
be  injected  through  the  long  Wales  bougie.  Hydrastis  and  hamamelis 
are  also  useful  for  this  purpose,  but  not  as  good  as  the  krameria. 

The  diet  is  of  the  utmost  importance,  and,  contrary  to  the  ordinary 
practice  in  these  cases,  that  recommended  by  Von  Noorden  has  been 
found  to  act  best.  This  consists  of  meats  in  abundance— beef,  mutton, 
13 


178  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

fowl,  fish,  eggs,  and  anything  of  the  nitrogenous  type  are  admissible;  of 
vegetables — the  leguminous  varieties,  together  with  those  of  a  fibrous  na- 
ture, such  as  spinach,  asparagus,  celery,  etc.^nay  be  allowed.  Starches, 
sweets,  coffee,  tea,  and  alcohol  should  all  be  avoided.  As  to  bread,  either 
Graham  or  whole  wheat  bread,  as  distinguished  from  those  made  from 
finer  flours,  are  the  best  to  use.  Corn-bread  is  much  relished  by  these  pa- 
tients, and  does  not  seem  to  have  any  ill  effect  when  made  without  sugar. 
All  wheat  breads  should  be  used  stale  or  toasted  to  avoid  the  fermentative 
action  of  improperly  cooked  yeast.  The  condition  of  achylia  reported 
by  Dr.  Einhorn  has  not  been  met  with,  and  it  can  only  be  said  that  when 
there  are  evidences  of  stomachic  indigestion,  of  whatever  type  it  may  be, 
it  should  be  attended  to  according  to  approved  methods. 

Therapeutic  remedies  seem  to  have  little  or  no  effect  except  to  relieve 
the  symptoms  temporarily;  pancreatin,  boric  acid,  ichthyol,  and  salol  are 
probably  the  most  satisfactory  drugs,  and  they  are  used  when  there  are 
flatulence  and  evidences  of  fermentation.  Tonics  are  indicated  in  those 
eases  in  which  there  are  feeble  circulation,  ansmia,  and  general  debility, 
but  iron  is  contraindicated  on  account  of  its  constipating  effects.  Drugs 
which  stimulate  the  appetite  and  assist  in  assimilation  seem  to  have  a 
good  effect.  Feeding  with  the  proper  character  of  food,  however,  is  the 
one  essential  indication.  As  Da  Costa  pointed  out  nearly  thirty  years 
ago,  the  milk  diet  does  more  harm  than  good.  Where  there  is  marked 
local  inflammation  in  the  rectum  and  sigmoid,  with  excoriation  or  ulcer- 
ation, local  treatment  to  these  conditions  should  be  carried  out  after  the 
methods  described  in  the  chapters  on  proctitis  and  ulceration  of  the  rec- 
tum. 

Outdoor  exercise  and  mental  and  physical  occupation  are  essential  to 
the  cure  of  these  patients,  especially  those  with  marked  depression  and  a 
tendency  toward  melancholia.  A  change  from  a  low,  damp  climate  to 
high,  dry,  mountainous  areas  is  frequently  of  benefit.  This,  however, 
is  not  essential,  as  the  condition  is  a  local  one  due  to  direct  or  reflex 
irritation,  and  when  these  exciting  causes  have  been  removed  the  mucous 
and  membranous  discharges  will  cease,  the  patient  will  begin  to  ingest 
and  assimilate  proper  quantities  of  food,  and  through  this  the  anaemia 
and  general  physical  debility  will  be  removed. 

Secondary  Membranous  Colitis. — This  term  is  given  by  Hale  White 
to  those  conditions  in  which  a  membranous  deposit  forms  upon  the  walls 
of  the  colon  secondary  to  some  other  grave  and  constitutional  disease. 
There  are  rarely  any  symptoms  of  the  condition  during  life  beyond  a  cer- 
tain amount  of  tenderness  over  the  region  of  the  colon  and  sigmoid. 
There  is  scarcely,  if  ever,  any  discharge  of  mucus,  and  diarrhoea,  if  there 
be  any,  is  generally  of  the  involuntary  type.  The  disease  is  therefore 
not  a  local  condition,  and  as  it  presents  few  symptoms  referable  to  the 


CHRONIC   COLITIS,  MUCOUS   COLITIS,   MEMBRANOUS   COLITIS     179 

lower  end  of  the  intestinal  tract,  its  full  consideration  here  would  be 
out  of  place.  Occasionally,  however,  in  the  course  of  such  diseases  rectal 
symptoms  develop ;  blood,  pus,  and  mucus  are  discharged,  and  the  rectal 
specialist  is  called  in  to  determine  the  nature  of  the  condition.  It  seems 
advisable,  therefore,  to  refer  briefly  to  the  caiises  of  this  condition,  and 
those  readers  who  are  interested  in  the  subject  can  follow  it  up  in  the 
Journal  literature  and  in  works  upon  general  medicine. 

First,  these  membranes  may  arise  from  traumatisms  to  the  colon,  or 
from  swallowing  some  corrosive  substances,  especially  tosic  doses  of 
mercury.  The  explanation  of  this,  as  given  b}'  Yirchow  (Berlin,  klin- 
ische  Wochenschrift,  1887,  Xo.  50)  is,  that  the  mercury  is  absorbed 
through  the  stomach  and  small  intestines  and  excreted  into  the  colon, 
thus  forming  an  irritation  or  inflanmiation  which  results  in  the  jDro- 
duction  of  the  mucus  or  so-called  membrane. 

Second,  this  condition  may  be  due  to  sepsis;  patients  with  acute 
septicaemia  in  which  the  whole  constitution  is  involved  in  the  toxic 
process,  with  great  debility,  impaired  circulation,  and  low  vitality,  are  all 
subject  to  this  disease.  The  colonic  symptoms  occur  late  in  the  affection, 
and  the  membranes  formed  are  rarely,  if  ever,  passed  during  life.  White 
cites  a  number  of  instances  in  which  these  membranes  were  found  post 
mortem :  among  them  a  case  of  gangrenous  umbilical  hernia ;  1  of  fatal 
puerperal  fever;  1  of  septicEemia  due  to  premature  labor  or  abortion,  in 
which  dark-green  patches  of  membrane  were  located  near  the  sigmoid 
flexure;  another  of  general  sepsis  with  gangrene  of  the  foot,  in  which 
there  were  grayish  leathery  membranes  formed  in  the  rectum  and  sig- 
moid flexure;  another  of  sepsis  and  general  cystitis,  in  which  the  mem- 
brane began  Just  within  the  anus  and  extended  for  3  inches  upward  as  a 
grayish-brown  coagulation  with  necrosis  and  submucous  haemorrhages 
extending  as  high  as  the  splenic  flexure,  and  finally,  one  of  acute  suppu- 
rative cellulitis  of  the  neck  with  whitish  patches  in  the  ascending  colon. 

There  is  nearly  always  some  involvement  of  the  kidneys  in  these 
conditions.  Constipation  is  more  frequent  in  these  cases  than  diarrlu^a. 
If  general  peritonitis  exists  there  will  be  tympanites,  and  sometimes  ana- 
sarca. The  author  has  seen  the  condition  once  in  a  case  of  gangrene  of 
the  leg  followed  by  general  septicemia,  three  times  in  cases  of  em- 
pyema with  symptoms  of  general  sepsis  before  death,  and  once  in  septic 
peritonitis  following  operation  in  a  case  in  which  a  large  tubal  abscess 
broke  into  the  peritonaeum. 

Third,  secondary-  membranous  colitis  may  occur  in  cases  of  chronic 
Bright's  disease;  both  simple  and  ulcerative  inflammation  of  the  rectum 
and  sigmoid  result  from  this  disease.  TVilks  and  ]\Ioxon  state  that  they 
observed  the  formation  of  a  tough  whitish  membrane  attached  to  the  mu- 
cous membrane  of  the  colon  in  patients  who  died  from  this  condition,  but 


180  THE  AXUS,  RECTUM,   AND   PELVIC  COLON 

they  do  not  state  whether  there  was  any  suppurative  inflammation  of  the 
kidneys  or  not.  Bristowe  and  Delafield  both  state  that  these  inflamma- 
tions of  the  colon  may  occur  in  the  late  stages  of  fatal  pneumonias. 
White  has  seen  cases  occur  during  the  course  of  fatal  diabetes,  and  Pye- 
Smyth  has  observed  it  in  a  case  of  carcinoma  not  connected  with  the 
intestine.  The  fact  that  the  condition  does  not  present  symptoms  during 
life,  that  it  is  rarely  observed  except  at  autopsies,  and  that  all  the  cases 
in  which  it  has  been  observed,  except,  perhaps,  in  a  few  following  mer- 
curic poisoning,  have  proved  fatal,  renders  a  discussion  of  the  treatment 
impossible  at  the  present  time. 

Ulcerative  Colitis. — Ulceration  of  the  colon  frequently  occurs  as  a 
result  of  Bright's  disease,  typhoid  fever,  tuberculosis,  dysentery,  and 
malignant  neoplasms.  It  is  frequently  found  in  the  post-mortem  room 
after  death  from  other  causes  in  patients  who  present  no  ante-mortem 
symptoms  of  the  condition,  and  whose  intestinal  functions,  so  far  as  their 
history  showed,  appeared  to  have  been  perfectly  normal  up  to  within  a 
short  time  before  death.  It  is  not  proposed  to  discuss  here  the  condition 
that  arises  from  these  speciflc  causes,  but  to  study  those  cases  of  simple 
ulcerative  colitis  with  chronic  diarrhoea  and  symptoms  referable  to  the 
rectum  and  lower  end  of  the  intestinal  canal. 

Etiology. — The  cause  of  ulceration  of  the  colon  can  not  always  be 
told.  In  some  cases  there  is  a  history  of  typhoid  fever,  dysentery,  or 
chronic  diarrhoea;  sometimes  it  develops  during  the  course  of  a  mem- 
branous colitis,  at  others  the  condition  seems  to  originate  suddenly  and 
without  any  premonitory  symptoms.  It  is  said  to  occur  frequently  in 
the  insane.  Campbell  (British  Journal  of  Mental  Sciences,  1898,  p.  526) 
reported  28  cases  that  occurred  in  the  institutions  for  the  insane  with 
which  he  was  connected.  Cowan,  Ackland,  and  Targett  claim  that  ulcer- 
ation of  the  colon  may  be  due  to  the  disease  of  the  central  nervous  sys- 
tem, and  White  has  reported  2  cases  that  occurred  in  Guy's  Hospital 
which  seem  to  corroborate  this  view. 

Cowan  calls  attention  to  the  frequent  occurrence  of  ulceration  of  the 
rectum  and  colon  in  the  insane.  Enrich  (Lancet,  May  18,  1895),  while 
admitting  that  this  is  the  fact,  states  that  the  lowered  vitality  of  luna- 
tics renders  them  an  easy  prey  to  all  sorts  of  diseases.  He  therefore 
believes  that  these  ulcerations  are  not  due  to  trophic  neuroses,  as  Ackland 
and  Targett  claim,  but  to  some  other  cause  that  operates  upon  these 
weakened  systems. 

Age  seems  to  have  some  influence  in  producing  it.  In  28  cases  re- 
ported by  White  and  Coleman,  seventeen  years  was  the  youngest  and 
fifty-nine  the  eldest.  In  the  autopsies  at  the  New  York  city  almshouse 
ulcerations  of  the  rectum  and  colon  are  among  the  most  frequent  patho- 
logical chancres.     Manv  of  these  have  been  due  to  tuberculosis  or  to 


CHRONIC  COLITIS,  MUCOUS  COLITIS,  MEMBRANOUS  COLITIS    181 

atheromatous  changes  in  the  blood-vessels.  The  condition  extended  in 
patches  from  the  rectum  to  the  caecum. 

Sex  seems  to  have  no  predominating  influence.  In  White's  cases 
there  were  fifteen  men  and  thirteen  women. 

Climate  and  occupation  have  not  been  shown  to  have  anj^  decisive 
influence  in  the  production  of  the  disease;  in  mild  climates  it  occurs 
quite  as  often  as  in  the  warmer  regions,  and  even  in  the  very  cold  sec- 
tions of  Eussia  and  the  high  mountainous  regions  of  the  United  States 
this  condition  seems  to  be  quite  as  frequent  as  in  the  other  sections. 
Laborers  in  lead  works,  and  miners  who  have  considerable  to  do  with 
quicksilver  and  mercuric  preparations,  seem  to  be  affected  with  the  dis- 
ease somewhat  more  frequently  than  those  engaged  in  other  industries. 
The  question  whether  the  absorption  of  the  metals  occasions  this,  or 
whether  the  constipation  produced  by  these  occupations  is  the  cause  of 
the  ulceration,  remains  yet  to  be  answered.  The  fact  that  the  disease 
occurs  most  frequently  in  anemic,  broken-down  individuals  suffering 
with  some  other  form  of  disease,  or  having  suffered  from  some  exhaustive 
condition,  makes  it  likely  that  these  ulcers  are  due  to  trophic  or  circula- 
tory changes.  On  the  other  hand,  they  may  be  due  to  the  invasion  of 
weakened  tissues  by  the  septic  bacteria  always  present  in  the  colon.  As 
a  matter  of  fact,  it  is  now  generally  believed  that  there  are  present  in  the 
human  system  at  all  times  the  elements  of  sepsis  and  toxemia,  and  that 
it  is  simply  a  question  of  perpetual  war  between  these  elements  and  the 
animal  tissues.  "When  the  system  is  in  a  normal,  strong,  and  healthy 
condition  it  resists  the  invasion  of  these  bacterial  enemies.  When  it  is 
weakened  by  improper  nourishment,  overwork,  anxiety,  or  disease,  the 
balance  is  thrown  to  the  other  side,  and  the  invasion  of  septic  bacteria 
becomes  effective  in  the  production  of  disease.  Such  may  be  the  cause  of 
these  ulcerations  in  the  rectum  and  colon.  The  balance  is  thrown  upon 
the  side  of  the  bacteria. 

There  is  often  a  history  of  some  organic  disease  of  the  heart,  liver, 
kidneys,  or  spleen,  but  Hale  White  says  in  one-half  of  the  cases  the  rest 
of  the  organs  are  perfectly  healthy.  Eheumatism  with  its  cardiac  com- 
plications, gout  with  its  thickened  and  calcareous  joints,  hepatitis  with 
abscess  and  biliary  disturbances,  and,  most  frequently  of  all,  diabetes  and 
chronic  Bright's  disease,  are  associated  with  this  form  of  colitis.  Camp- 
bell {loc.  cit.)  found  chronic  Bright's  disease  in  11  out  of  28  cases  of 
ulcerative  colitis,  and  8  out  of  18  cases  of  membranous  colitis.  Cowan 
reports  a  similar  state  of  affairs  in  the  institutions  over  which  he  has  con- 
trol. The  author  has  seen  2  cases  of  the  disease  in  which  there  was 
marked  diabetes,  and  in  1  the  glycosuria  amounted  to  6  per  cent.  Yet 
the  very  large  number  of  all  these  diseases  that  are  not  associated  with 
ulcers  of  the  colon  renders  the  conclusion  necessary  that  they  are  not 


182  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

exciting  but  rather  predisposing  causes  to  the  condition.  This  is  throw- 
ing us  back  once  more  upon  the  theoretical  conclusion  that  the  disease  is 
due  to  the  invasion  of  specific  bacilli  under  the  circumstances  favorable 
to  their  excessive  development. 

Pathology. — Much  has  been  written  and  said  about  the  patholog}'  of 
ulcerative  colitis,  and  yet  there  seems  to  be  very  little  harmony  of  opinion 
with  regard  to  the  same.  The  ulcers  may  be  found  anywhere  from  the 
anal  margin  to  the  tip  of  the  appendix,  even  this  latter  organ  being  some- 
times involved.  Their  depth  and  extent  are  very  variable,  at  times 
being  the  size  of  a  split  pea,  at  others  being  as  large  as  a  silver  quarter, 
and  gradually  sloping  do^\Ti  to  the  base;  occasionally  they  involve  the  en- 
tire circumference  of  the  colon.  The  muscular  wall  of  the  gut  usually 
forms  the  base  of  the  ulcer,  but  sometimes  they  are  superficial  and  may 
not  extend  to  the  submucous  tissue;  in  other  cases  they  penetrate  the 
muscular  wall  and  even  the  peritonseum,  but  usually  this  membrane  is 
healthy  over  the  seats  of  the  ulcers.  The  mucous  membrane  between  the 
ulcerated  areas  is  dark,  purplish,  and  congested. 

The  tendency  of  ulcers  is  to  extend  circularly  around  the  intes- 
tine. They  may  be  so  numerous,  however,  that  only  small  patches  of 
mucous  membrane  remain,  which  patches  White  describes  as  having  a 
sort  of  polypoid  appearance,  and  even  having  been  mistaken  for  polypi. 
He  reports  a  case  in  which  there  were  over  one  hundred  superficial  ulcers ; 
the  author  has  recently  seen  a  similar  case  in  which  there  was  scarcely  a 
square  inch  of  mucous  membrane  between  the  anus  and  the  caecum. 
Omerod  and  Barlow  reported  cases  in  which  there  were  numerous  per- 
forations at  one  time.  Delafield  stated  that  the  follicles  are  infiltrated, 
swollen,  and  break  down,  forming  what  he  terms  "  productive  ulcers," 
which  from  his  descriptions  closely  tally  with  those  referred  to  here. 
The  early  ulcers  seem  to  develop  either  along  the  lines  of  the  mesen- 
tery or  of  the  longitudinal  folds.  The  epithelium  of  the  Lieberklihn  fol- 
licles is  clouded  and  swollen;  there  is  an  accumulation  of  small  cells  in 
the  submucous  layer  which  is  oedematous  and  thickened,  and  thus  narrows 
to  a  certain  extent  the  caliber  of  the  gut.  The  follicles  may  be  the  seat 
of  ulcers  or  they  may  be  cut  off  flush  with  the  ulcerated  surface,  leaving 
a  portion  of  them  below  this  surface. 

Symptoms. — The  disease  may  begin  in  a  variety  of  ways.  Delafield 
states  that  in  the  large  majority  of  instances  it  begins  in  the  rectum  and 
travels  upward.  White  says  that  it  may  begin  at  any  point  in  the  whole 
course  of  the  large  intestine.  In  some  cases  there  is  a  sudden  onset  of 
sharp  lancinating  pains  in  the  course  of  the  colon  attended  with  griping 
and  a  tendency  to  frequent  movements  of  the  bowels.  These  pains  last 
for  a  short  while,  disappear,  and  the  patient  may  feel  nothing  more  of 
the  kind  for  several  days  or  weeks,  when  they  occur  again.     They  last 


CHRONIC  COLITIS,  MUCOUS  COLITIS,  MEMBRANOUS  COLITIS    183 

sometimes  an  hour  or  more,  at  others  they  continue  for  two  or  three 
days.  The  stools  do  not  at  first  contain  any  mucus,  pus,  or  blood,  but  if 
the  pain  is  persistent,  and  the  recurrence  frequent,  there  will  be  evi- 
dences of  ulceration  in  the  discharge  of  these  substances.  If  the  ulcer  is 
high  up  the  blood  and  pus  will  be  mixed  with  the  stool,  and  the  blood  will 
be  dark  and  decomposed  or  clotted;  if  it  is  in  the  lower  part  of  the  sig- 
moid flexure  or  in  the  rectum,  the  blood  will  be  fresh  and  will  precede 
the  stool.  The  periodical  occurrences  are  said  by  White  to  be  typical 
of  the  disease.  The  pain,  which  in  the  first  attacks  is  not  very  severe,  in- 
creases with  each  recurrence.  The  amount  of  pain  bears  no  relationship 
to  the  amount  of  ulceration,  nor  is  it  influenced  by  the  ingestion  of  food. 
The  cause  of  pain  is  probably  not  in  the  existence  of  an  ulcer,  but  in  the 
irritation  of  the  ulcer  by  the  intestinal  contents,  which  sets  up  irregular 
peristaltic  or  spasmodic  action  of  the  bowel.  The  number  of  the  stools 
varies  greatly;  in  one  case  there  were  35  to  36  stools  a  day  for  one  week 
during  the  acute  attack,  in  others  the  number  reached  anywhere  from  5  to 
15  or  20  stools  a  day.  The  diarrhoea  may  alternate  with  short  periods  of 
constipation.  A  distinction  between  the  diarrhoea  in  these  cases  and  that 
in  dysenteric  and  acute  catarrhal  inflammations  of  the  rectum  and  colon 
should  be  clearly  understood.  In  the  latter  conditions  there  is  a  con- 
stant tenesmus  and  desire  to  go  to  the  water-closet,  a  feeling  of  incom- 
pleteness in  the  defecatory  act,  a  desire  to  remain  straining  upon  the 
seat.  In  this  condition,  however,  the  inclination  is  not  continuous.  It 
is  frequent  and  imperative  at  the  time.  The  bowels  having  once  moved, 
there  is  complete  relief  for  the  time  being.  The  patient  does  not  suffer 
in  the  interim,  but  after  a  while  the  imperative  demand  recurs,  and  must 
be  yielded  to  at  once.  The  stools  may  be  thin  and  watery,  or  they  may  be 
semifluid.  Sometimes  hard  fgecal  balls,  as  in  mucous  or  membranous 
colitis,  occur,  but  this  is  not  the  rule.  They  are  generally  semifluid  and 
possess  a  foul,  feculent  odor,  which  is  often  very  suggestive  of  malignant 
disease.  Mucus  is  not  generally  present,  but,  as  said  above,  blood  and 
pus  soon  begin  to  appear  in  the  stools.  When  the  blood  occurs  as  a  clot, 
it  is  sometimes  smooth  on  one  side  and  rough  on  the  other,  showing  that 
it  has  recently  been  detached  from  the  floor  of  an  ulcer  (White) .  Along 
with  the  blood  and  pus  there  may  come  shred-like  masses  of  sloughing 
material  containing  leucocytes,  epithelial  cells,  and  small  adherent 
masses  of  fsecal  matter. 

A^omiting  is  said  to  be  an  early  symptom  in  the  disease,  but  in  the 
author's  experience  it  has  only  occurred  in  occasional  and  in  very 
severe  attacks.  When  the  nausea  and  vomiting  are  very  severe  blood 
may  be  contained  in  the  vomited  material,  but  this  is  generally  due 
to  the  rupture  of  some  small  venule  in  the  throat  or  oesophagus,  and 
does  not  come  from  the  ulcers  of  the  intestine.     The  tongue  is  at  first 


184  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

coated  with  a  white  furry  coat,  but  it  soon  becomes  red  upon  tlie 
edges  and  more  or  less  brown  in  the  middle,  very  much  resembling 
the  tongue  of  typhoid  fever.  The  patients  suffer  greatly  from  thirst. 
Progressive  anaemia,  loss  of  flesh  and  strength,  and  great  depression  in 
spirits  are  the  natural  sequences  of  the  disease.  The  temperature  in 
the  disease  is  very  irregular;  in  some  cases  it  never  goes  above  100°  F. 
during  the  whole  course  of  the  malady,  in  other  cases  the  temperature 
has  gone  as  high  as  104.5°  F.,  and  may  vary  at  times  4  degrees 
between  night  and  morning.  It  sometimes  drops  below  normal,  and 
within  a  few  hours  is  up  again  some  3  or  4  degrees.  The  condition 
resembles  very  closely  typhoid  fever  with  ulceration  of  the  bowel. 

The  course  of  the  disease  may  be  very  short,  patients  having  died 
from  it  in  three  or  four  days.  Such  a  result,  however,  is  probably 
due  to  perforation  and  subsequent  peritonitis.  Under  other  circum- 
stances death  from  ulceration  occurs  after  long  periods  of  suppura- 
tion and  general  sloughing  of  the  mucous  membrane  of  the  intestine, 
and  it  is  then  due  to  exhaustion  or  amylaceous  degeneration  of  the 
organs.  White  states  that  the  prognosis  is  always  grave,  and  that 
he  is  exceedingly  doubtful  in  any  case  that  recovers  whether  after  all 
the  diagnosis  was  correct.  The  course,  he  says,  is  fatal  in  about  eight 
weeks.  Continuous  high  temperature,  persistent  pain,  tympanites,  and 
very  frequent  stools  associated  with  the  loss  of  blood  and  increased 
purulent  discharge,  are  all  unfavorable  symptoms. 

Diagnosis. — It  is  likely  to  be  confounded  with  but  three  conditions, 
viz. :  dysentery,  typhoid  fever,  and  malignant  disease  of  the  large  intes- 
tine. Eeference  has  been  made  to  the  distinction  between  dysentery 
and  typhoid  fever  and  this  disease.  In  malignant  disease  the  onset  is 
very  much  more  gradual,  the  temperature  is  never  high  except  in  the 
very  last  stages,  the  patient  is  not  troubled  with  griping  or  diarrhoea, 
but  generally  with  constipation  that  requires  cathartics  to  move  the 
bowels ;  after  the  movement  has  once  been  obtained,  the  patient  seems 
fairly  comfortable  for  some  time,  later  on  the  passing  of  mucus  and 
blood  are  indicative  of  malignant  disease.  One  who  is  thoroughly 
versed  in  the  examination  of  malignant  diseases  of  the  intestine  will 
rarely  be  deceived  by  anything  else,  for  the  peculiar  feculent,  path- 
ognomonic odor  from  malignant  ulcers  is  characteristic.  In  ulceration 
of  the  colon  there  is  rarely  any  discharge  of  glairy  mucus,  but  the 
sanious  pus  is  very  abundant. 

Treatment. — So  far  as  any  local  influence  of  medication  goes,  no 
definite  results  seem  to  have  been  obtained  in  these  cases  by  adminis- 
tration through  the  mouth.  The  chief  indication  seems  to  be  to  find 
out  the  cause  of  the  debilitated  condition  of  the  system  and  treat  that 
as  far  as  possible.     The  ulcerated  colon  and  rectum  themselves  need 


CHRONIC  COLITIS,  MUCOUS  COLITIS,   MEMBRANOUS  COLITIS    185 

local  treatment  together  with  a  bland,  unirritating  diet  in  order  to 
prevent  further  irritation  and  multiplication  of  the  ulcers.  Ordinary 
irrigation  of  the  rectum  through  the  rectal  irrigator  is  of  no  practical 
benefit  in  these  cases,  as  the  fluid  does  not  reach  high  enough.  The 
use  of  long  bougies,  even  of  the  soft-rubber  type,  is  dangerous,  because 
the  rectal  wall  at  the  ulcerated  spots  is  liable  to  be  so  thin  that  even 
the  slightest  distention  or  pressure  may  rupture  it  and  set  up  a  fatal 
peritonitis. 

The  treatment  that  affords  the  most  benefit  is  this:  Place  the  pa- 
tient in  the  semiknee-chest  posture  by  elevating  the  hips  upon  two 
or  three  pillows  and  letting  the  shoulders,  chest,  and  knees  rest  upon 
the  surface  of  the  bed;  in  this  position  introduce  the  rectal  tip  of  an 
ordinary  fountain  S}Tinge  into  the  rectum;  elevate  the  fountain  only 
about  2  feet  above  the  level  of  the  patient,  and  then  turn  on  the  stream 
and  let  the  fluid  flnd  its  way  into  the  colon.  By  requiring  the  patient 
to  remain  in  this  position  for  ten  or  fifteen  minutes,  breathing  gently 
but  deeply,  the  fluid  will  gradually  pass  into  the  intestinal  canal  so 
slowly  that  there  is  no  danger  of  distention  and  very  little  tendency 
of  the  bowels  to  reject  it.  The  fluid  should  be  started  at  about  105° 
or  110°  F.,  as  it  will  gradually  cool  off  during  the  slow  instillation. 
By  this  means  it  is  possible  to  reduce  the  frequency  of  the  stools, 
to  check  the  discharge  of  blood,  and  together  with  proper  regimen, 
diet,  and  tonic  medication,  to  restore  the  patients  to  health.  The 
fluid  injected  has  been  one  of  two  remedies :  either  the  aqueous 
fluid  extract  of  krameria^  which  seems  to  act  better  than  anything 
else  so  far  as  checking  the  diarrhoea  and  haemorrhage  is  concerned,  or 
the  fluid  extract  of  hamamelis.  The  strength  of  these  solutions  de- 
pends largely  upon  the  condition  of  the  patient  and  the  sensitiveness 
of  the  colon;  in  some  cases  the  krameria  may  be  used  as  strong  as  20 
per  cent,  in  others  it  may  be  used  in  the  strength  of  5  per  cent.  Ham- 
amelis is  not  used  stronger  than  10,  and  generally  in  from  1-  to  3- 
per-cent  solutions.  The  amount  of  the  latter  used  vanes  from  1  to 
6  pints,  and  the  patient  is  required  to  retain  it  as  long  as  possible. 
When  the  haemorrhages  are  frequent,  in  the  commencement  of  the 
treatment  a  combination  of  ergot,  cinnamon,  and  hydrastis  may  be 
used  internally;  gelatin  has  been  recently  advised  for  this  purpose, 
but  the  author  has  had  no  experience  with  it;  by  the  combination 
of  these  remedies  with  the  irrigation  mentioned  above  the  liEemor- 
rhages  may  be  checked  very  promptly  in  all  the  cases.  The  ulcera- 
tion, however,  is  a  more  obstinate  affair,  and  its  cure  dej^ends  not 
only  on  keeping  the  intestine  free  from  irritating  substances  and 
washing  out  the  septic  germs,  but  also  upon  building  up  the  patient's 
general  condition.     Stimulation  of  the  assimilative  organs  and  the  ad- 


186  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

ministration  of  predigested  and  nourishing  foods  are  of  the  utmost 
importance.  Bone  marrow,  hsemaboloids,  protonuclein,  fresh  beef 
juice,  plasmon,  and  such  remedies  are  used  in  small  quantities  and 
frequently,  together  with  a  sufficient  amount  of  rich  Burgundy  wine 
as  a  stimulant  to  the  heart  and  digestion.  \Yhen  these  local  and  gen- 
eral measures  fail  recourse  may  be  had  to  functional  rest  of  the  parts 
by  making  an  artificial  anus  above  the  ulcerated  portion.  Thus  far 
the  author  has  not  found  one  whose  condition  would  admit  of  it  who 
would  give  his  consent  to  having  a  right  inguinal  anus  made.  So  long 
as  they  are  not  desperately  ill  the  patients  cling  to  the  belief  in  medi- 
cation and  local  treatment  without  operation.  White  holds  that 
when  the  disease  shows  no  inclination  to  heal  by  local  treatment,  a 
right-side  inguinal  colotomy  is  not  only  justifiable  but  imperative.  He 
recommends  the  injection  of  a  25-per-cent  solution  of  perchloride  of 
iron  as  high  up  in  the  colon  as  possible,  in  order  to  control  hsemorrhage; 
but  the  author  has  elsewhere  expressed  his  objections  to  this  remedy, 
and  need  not  repeat  them  here.  Delafield,  Da  Costa,  W.  H.  and  W.  K. 
Thompson  all  advise  the  use  of  castor-oil  in  small  doses  for  the  relief 
of  diarrhoea.  The  author  has  tried  it  many  times  and  finds  its  action 
very  uncertain;  sometimes  it  seems  almost  a  specific  in  the  early  stages 
of  the  disease,  while  in  others  it  seems  absolutely  useless,  so  that  he 
has  come  to  doubt  its  efficacy  in  true  cases  of  ulcerative  colitis. 

Follicular  Colitis. — Scattered  throughout  the  mucous  membrane  of 
the  rectum,  sigmoid,  and  colon,  there  are  a  large  number  of  solitary 
follicles,  upon  the  function  of  which  physiologists  fail  to  throw  any 
light.  They  are  not  glandular  in  their  structure ;  they  are  neither 
secretive  nor  absorptive.  They  are  much  more  frequent  in  the  colon 
than  in  the  sigmoid  and  rectum.  Their  seat  is  in  the  mucous  mem- 
brane proper,  but  their  bases  dip  down  into  the  submucous  tissue. 
During  the  course^  or  as  a  result  of  chronic  catarrhal  infiammations, 
these  follicles  become  inflamed,  the  pressure  upon  the  membrane  above 
them  results  in  a  necrosis,  and  small^  well-defined,  circular  ulcers 
are  left. 

White  states  that  this  disease  occurred  about  once  in  five  hundred 
post  mortems  made  at  Guy's  Hospital,  London.  In  a  large  number  of 
autopsies  made  at  the  New  York  City  i\.lmshouse  during  the  last  six 
years  only  3  cases  of  this  condition  have  been  observed.  Notwithstand- 
ing the  fact  that  White  says  the  condition  is  never  diagnosed  during 
life,  the  writer  has  seen  and  recognized  5  cases  of  this  kind  in  his 
clinic  and  private  practise.  In  2  of  these  the  disease  was  chiefly  in  the 
sigmoid,  in  2  it  was  just  below  the  recto-sigmoidal  juncture,  and  in  1 
it  was  at  the  lower  end  of  the  rectum. 

Etiology. — The  cause  of  this  condition  is  very  imperfectly  known. 


CHRONIC  COLITIS,  MUCOUS  COLITIS,  MEMBRANOUS  COLITIS    187 

It  occurs  during  the  course  of,  or  as  the  result  of,  other  inflammatory 
diseases.  Holt  reports  having  seen  the  condition  20  times  in  70  fatal 
cases  of  non-tubercular  diarrhoea  in  infants;  he  states  that  it  never 
occurred  in  cases  of  less  than  one  week's  duration,  and  it  was  more 
frequent  in  those  that  lasted  longer  than  eight  or  ten  weeks.  In  the 
20  cases  the  ulcers  were  confined  to  the  colon  in  15,  to  the  small 
intestine  in  2,  and  were  found  in  both  3  times.  Those  which  were 
found  in  the  small  intestine  were  in  the  lower  end  of  the  ileum  near 
the  csecum.  Those  in  the  colon  were  most  frequent  in  the  sigmoid 
flexure,  the  lower  portion  of  the  descending  colon,  and  the  rectum. 
In  the  cases  reported  by  White  all  of  them  are  said  to  have  died  from 
some  other  disease,  such  as  dysentery,  cancer,  membranous  colitis,  ty- 
phoid fever,  or  tuberculosis.  He  calls  attention  to  the  fact  that  in  the  5 
cases  which  died  from  tuberculosis  and  in  which  he  found  follicular 
ulceration  of  the  colon,  there  was  not  a  single  instance  of  tubercular 
ulceration  of  this  organ. 

In  the  cases  observed  at  the  almshouse  2  were  in  tubercular  patients 
and  1  in  a  case  of  chronic  ulceration  of  the  colon.  In  the  tubercular 
cases  the  autopsies  confirmed  the  statement  of  White,  and  in  the 
other  case  the  follicular  ulcers  were  dotted  here  and  there  between 
the  larger  ulcerations.  In  none  of  these  cases  were  any  tubercle  bacilli 
or  giant  cells  found  in  the  ulcers.  In  the  author's  clinical  cases  2  gave 
a  history  of  having  had  "  acute  dysentery,"  which  had  resulted  in  a 
chronic  diarrhoja,  with  hard,  lumpy  stools  occasionally;  upon  examina- 
tion there  were  evidences  of  typical  hypertrophic  catarrh.  In  another 
there  was  obstruction  in  the  sigmoid  and  colon  which,  upon  explora- 
tory laparotomy,  proved  to  be  due  to  adhesive  bands.  These  were 
broken  down,  and  under  rest,  proper  diet,  and  sigmoidal  irrigation  the 
condition  disappeared.  In  the  fifth  case,  in  which  the  inflammation 
was  centered  around  the  lower  portion  of  the  rectum,  there  was  a 
history  of  chronic  constipation,  operations  for  hgemorrhoids,  stretching 
of  the  sphincter,  and  much  instrumental  interference  with  the  organ. 
All  of  these  cases,  therefore,  were  associated  with  or  followed  some 
inflammatory  process  in  the  walls  of  the  intestine.  So  far  a  case  of 
simple,  uncomplicated,  follicular  inflammation  of  the  colon  or  rectum 
has  not  been  met  with. 

Pathology. — The  pathological  changes  in  this  form  of  inflammation 
consist  in  a  congestion  of  the  mucous  membrane  around  the  follicles 
with  hyperplasia  and  an  accumulation  of  small,  round  cells  inside  of 
them  (Fig.  87).  As  this  increases  the  follicle  becomes  distended  and  ele- 
vated above  the  level  of  the  mucous  membrane.  Pressure  from  this  dis- 
tention and  friction  from  the  passage  of  the  fgecal  mass  over  it  cause 
necrosis  of  the  epithelial  covering  and  rupture  of  the  wall  of  the  foUi- 


188 


THE  ANUS,   RECTUM,   AND   PPXVIC   COLON 


cle.  This  leaves  an  ulcer  with  sliariily  cut  edges,  slightly  unJennined, 
and  with  a  flat  base,  never  crater-like.  The  ulcers  are  not  deep,  and 
rarely  coalesce,  although  the  whole  gut  may  be  honeycombed  with  them 
(Fig.  88).    They  vary  in  size  from  a  hemp-seed  to  a  split  pea. 


"*- 


::;m. 


■?s>- 


-■-':■   'V-'t  A 


Fig.  87. — Transverse  Section  of  Ixplamed  Follicle. 


"\Miite  and  Holt  state  that  they  show  no  tendency  whatever  to  heal, 
but  in  the  fifth  ease,  mentioned  above,  and  in  which  the  affected 
mucous  membrane  was  removed,  there  were  several  cicatrices  which 
seemed  to  have  originated  in  follicular  ulcers  that  had  healed.  So  far 
no  case  of  perforation  of  the  gut  from  this  condition  has  been  recorded. 


Fig.  s8.- 


-Gross  Appearance  of  Mucous  Membrane  in  Follicular  Colitis 
fDelafield  and  Pruden). 


Gaylord  and  Aschoff  (Pathological  Histolog}%  p.  168)  have  observed 
a  condition  which  they  denominate  "  colitis  cystica  ";  it  appears  to  be 
very  similar  to  follicular  colitis.  They  state  that  in  chronic  inflamma- 
tions of  the  colon  the  mucoits  membrane  is  studded  with  minute,  clear 
vesicles  which  are  produced  by  dilatation  of  the  gland  lumina,  the 


CHRONIC  COLITIS,  MUCOUS  COLITIS,  MEMBRANOUS  COLITIS    189 

openings  of  wliicli  have  become  occluded.  Chronic  irritation  of  the 
mucous  membrane,  they  claim,  causes  agglutination  of  the  mouths  of 
the  glands,  and  the  continued  secretion  of  the  glands  thus  closed  re- 
sults in  small  spherical  cysts  which  project  above  the  surface  of  the 
gut.  The  clinical  symptoms  and  macroscopical  appearances  described 
by  these  authors  coincide  with  those  of  follicular  colitis.  The  patho- 
logical changes,  however,  and  the  manner  in  which  the  cysts  are  formed 
differ  materially  from  those  ordinarily  described  in  this  disease.  It 
remains  to  be  determined,  therefore,  whether  this  is  another  disease  or 
a  new  pathology  for  the  old  one.  The  author  recently  removed  a  small 
spherical  mass  from  the  rectum  the  histological  examination  of  which 
seemed  to  point  to  the  latter  view. 

Symptoms. — The  symptoms  in  these  cases  are  very  similar  to  those 
of  chronic  inflammation  of  the  rectum  and  colon,  and  vary  according 
to  the  site  of  the  affection.  AAHiere  the  disease  is  found  in  the  sigmoid 
flexure  and  colon  the  symptoms  are  those  of  chronic  hypertrophic  ca- 
tarrh. When  it  occurs  below  the  recto-sigmoidal  juncture  the  patients 
suffer  chiefly  from  muco-purulent  discharges,  frequent  desire  to  defecate 
without  any  results,  tenderness  over  the  lower  end  of  the  spine,  and 
vague  pains  shooting  down  the  legs. 

In  the  case  in  which  the  disease  was  limited  to  the  lower  end  of 
the  rectum  the  patient's  symptoms  were  those  of  ulceration  of  the 
rectum  and  anus.  She  had  already  had  an  operation  for  hgemorrhoids 
four  months  previous  to  consultation  for  the  new  condition.  The 
wound  from  this  operation  had  not  healed,  and  there  remained  a 
chronic  ulceration  in  the  anterior  left  quadrant  of  the  rectum.  The 
patient  had  frequent  painful  movements  composed  of  pus  in  abun- 
dance, some  mucus  and  blood.  Every  two  or  three  days  she  passed 
small  balls  of  faecal  matter,  which  became  coated  with  the  contents  of 
the  rectum  through  which  they  passed.  The  ulcer  in  this  case  prac- 
tically obscured  the  symptoms  of  follicular  disease,  and  the  diagnosis 
was  made  solely  upon  ocular  examination.  The  condition  was  so 
marked  that  its  benign  nature  was  doubted;  all  the  affected  mucous 
membrane  was  excised  and  submitted  to  the  pathologist  for  examina- 
tion. 

Pathological  Report  hy  Dr.  F.  M.  Jeffries : 

' '  The  macroscopical  appearance  is  as  though  the  mucosa  were  thicklj^  beset 
with  miliary  tubercles.  Each  nodule  is  round,  projects  slightly  above  the  surface, 
and  is  yellowish  in  color.  So  numerous  are  they  that  each  appears  to  be  in  con- 
tact with  its  neighbor.  The  submucosa  and  muscular  coats  appear  to  be  unaffected 
and  devoid  of  induration. 

"Microscopically  the  mucosa  is  beset  with  solitary  follicles  or  small  masses  of 
lymphadenoid  tissue  that  resemble  in  all  respects,  except  numbers,  the  normal  soli- 
tary follicles. 


190  THE  ANCS,  RECTUM,  AND  PELVIC  COLON 

"Between  the  follicles  the  crypts  of  Lieberkiihn  are  normal,  as  are  also  the 
submucous  and  muscular  coats. 

"At  one  point  where  tissue  was  selected  for  microscopical  examination,  granu- 
lation tissue  was  observed  associated  with  the  submucosa — probably  the  site  of  a 
previous  operation." 

All  of  these  cases  suffered  from  flatulence  and  digestive  derange- 
ments; they  found  little  relief  from  the  use  of  laxatives  and  remedies 
for  indigestion.  In  one  case  the  patient  suffered  with  the  most  aggra- 
vated symptoms,  such  as  alternating  diarrhoea  and  constipation,  dis- 
charges of  pus  with  thin  mucus,  followed  by  extreme  exhaustion  and 
tenderness  all  over  the  abdomen.  Upon  laparotomy,  adhesive  hands 
were  found  which  produced  a  constriction  of  the  gut;  these  were 
broken  down  and  the  bowel  released.  In  the  walls  of  the  ileum  and 
throughout  the  colon  there  were  myriads  of  little  hard  bodies  about 
the  size  of  Xo.  2  shot,  some  of  them  as  large  as  a  small  pea.  The 
intestine  was  not  opened  to  determine  the  nature  of  these  bodies,  hut 
there  is  little  doubt  that  they  were  inflamed  solitary  follicles.  Ex- 
amination of  the  three  other  cases  through  the  sigmoidoscope  showed 
here  and  there  little  nodular  swellings  when  the  intestine  was  put 
upon  the  stretch.  The  summits  of  these  elevations  were  sometimes 
abraded  and  bled  upon  touch  (Plate  I,  Fig.  3).  In  the  other  cases 
the  elevations  had  disappeared  and  in  their  places  there  were  small, 
well-defined,  shallow  ulcers.  The  bases  of  these  ulcers  were  smooth, 
flat,  and  granulating.  The  mucus  secreted  was  not  so  abundant  as  that 
in  hypertrophic  catarrh  nor  so  thick  and  tenacious  as  that  in  the 
atrophic  variety.  At  the  same  time  this  condition  may  be  complicated 
by  either  of  these  varieties  of  inflammation,  and  consequently  one  can 
not  place  much  dependence  upon^  the  character  of  the  discharges. 
"WTien  the  disease  is  situated  laTC.>down,  one  may  feel  with  the  finger 
small  nodular  elevations  giving  the  impression  of  miliary  tuberculosis, 
but  this  location  of  the  disease  is  so  rare  that  few  physicians  will  ever 
have  the  opportunity  of  feeling  it.  The  diagnosis  practically  depends 
upon  the  sigmoidoscope  and  ocular  examination  through  it. 

Treatment. — The  treatment  in  this  condition  depends  upon  the 
cause  and  the  location  of  the  ulcers.  Where  there  are  evidences  of 
intestinal  obstruction,  such  as  in  the  case  related  above,  they  should 
be  removed.  Where  there  is  a  catarrhal  condition  of  the  rectum  and 
sigmoid,  the  treatment  should  be  based  upon  the  character  of  this 
disease.  If  the  ulcerations  are  in  the  sigmoid  and  rectum  within  view 
through  the  sigmoidoscope,  local  applications  of  argonin,  nitrate  of 
silver,  or  antinosine  may  be  made. 

^Tiile  there  is  some  tendency  to  diarrhoea  and  frequent  movements 
of  the  bowels,  this  can  be  controlled  better  by  thoroughly  flushing  out 


CHRONIC  COLITIS,  MUCOtJS  COLITIS,  MEMBRANOUS  COLITIS    191 

the  inte.stine  by  a  good  dose  of  Epsom  salts  or  castor-oil  every  second 
or  third  morning  than  by  the  use  of  opiates.  The  case  in  which  the 
disease  was  located  at  the  lower  end  of  the  rectum  appears  to  be  unique. 
The  treatment  adopted^  viz.,  the  excision  of  all  the  diseased  mucous 
membrane  and  suturing  together  the  healthy  edges,  proved  perfectly 
satisfactory  for  the  time  being,  but  the  period  that  has  elapsed  since 
the  operation  is  too  short  to  claim  for  it  radical  and  permanent  cure. 

If  the  condition  should  be  diagnosed  as  existing  in  the  upper  por- 
tion of  the  sigmoid  and  colon,  it  should  be  treated  as  advised  for 
ulcerative  colitis.  In  those  cases  in  which  this  disorder  is  complicated 
by  membranous  colitis  the  treatment  will  be  necessarily  tedious  and 
prolonged,  and  one  may  be  finally  compelled  to  make  a  right  colostomy 
in  order  to  afford  the  parts  functional  rest. 

The  disagreeable  features  of  this  method  of  treatment  have  been 
largely  overcome  by  Gibson's  "  valvular  colostomy  "  (Medical  Eecord, 
1901,  vol.  i,  p.  405;  Boston  Medical  and  Surgical  Journal,  vol.  i,  1903), 


Fig.  88  A. — First  Tier  of  Sutures  in  Valvular  Colostomy  (Gibson). 


which  is  applicable  to  all  forms  of  chronic  colitis,  and  is  carried  out  as 
follows :  The  csecum  is  exposed  by  an  intermuscular  incision  an  inch  and 
a  half  long  parallel  to  and  Just  above  Poupart's  ligament.  An  opening 
is  then  made  in  the  anterior  longitudinal  band  of  the  gut  sufficiently 
large  to  admit  a  good-sized  soft -rubber  catheter.  Two  or  three  tiers  of 
sutures  are  then  introduced  in  the  serous  surface  of  the  gut  (Figs.  88  A 
and  88  B),  so  as  to  infold  the  latter  and  form  a  sort  of  teat  or  valve 
protruding  into  the  caliber  of  the  intestine  (Fig.  88  C).  The  ends  of  the 
last  tier  of  sutures  are  left  long,  and  carried  through  the  edges  of  the 
abdominal  wound,  thus  closing  the  latter,  at  the  same  time  holding  the 
gut  in  apposition  with  the  abdominal  wall.  The  catheter  is  left  in  for 
ten  days  or  more,  until  the  parts  have  healed.     After  this,  it  is  taken 


192 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


out  and  reintroduced  as  often  as  is  necessary  for  the  purposes  of  irri- 
gation. The  slight  fa?cal  fistula  is  controlled  by  a  small  pad,  and  the 
patient  is  not  confined  during  the  treatment. 

By  this  means  the  entire  colon  is  irrigated  from  above  downward 
with  medicated  solutions,  according  to  the  judgment  of  the  surgeon. 


Fig.  88  B. — Last  Tier  of  Sutures  in  Gibson's  Method. 

Bolton  in  his  case  used  nitrate  of  silver  0.01  per  cent,  followed  by  a 
saline  solution  0.05  per  cent. 

The  operation  is  practically  without  danger,  and,  while  it  does  not 
turn  the  faecal  current  aside  and  give  functional  rest  to  the  colon,  it 
enables  one  to  keep  the  latter  free  from  irritating  substances  by  frequent 


Fig.  88  C. — Longitudinal  Section  showing  Kesults  of  Infolding  by  Gibson's  Method. 


irrigation,  and  at  the  same  time  avoids  the  disagreeable  features  of  an 
artificial  anus.  The  small  fa-cal  fistula  will  close  spontaneously  after  tlie 
use  of  the  catheter  is  discontinued,  or  if  it  does  not,  it  is  an  easy  matter 
to  dissect  it  out  under  cocaine  anaesthesia  and  close  it  by  sutures. 


CHAPTER   VI 

TUBERCULOSIS  OF   THE  ANUS,   RECTUM,   AND  PELVIC  COLON 

TuBEKCULOSis  is  now  recognized  as  the  etiological  factor  in  a  number 
of  conditions  about  the  anus  and  rectum,  the  pathology  of  which  was 
formerly  unknown.  The  disease  may  develop  primarily  or  secondarily 
in  the  skin,  muco-cutaneous,  mucous,  and  cellular  tissues,  and  is  always 
due  to  the  tubercle  bacillus. 

In  the  skin  and  mucous  membrane  it  assumes  some  interesting  types, 
each  of  which  was  not  long  ago  considered  to  have  a  special  pathology, 
but  which  are  now  known  to  be  due  to  this  specific  microbe.  In  the 
cellular  tissues  it  develops  abscesses  and  fistulas,  and  in  the  muscles  fatty 
or  destructive  changes,  which  permanently  disable  them.  It  is  propa- 
gated by  direct  invasion  of  the  adjacent  tissues  or  through  the  lym- 
phatics. It  advances  in  inverse  proportion  to  the  amount  of  fibrous 
tissue  in  its  path ;  a  pure  cicatrix  forms  a  barrier  through  which  it 
can  not  pass.  In  the  present  chapter  tubercular  lesions  of  the  skin, 
muco-cutaneous  tissue,  and  mucous  membrane  will  be  considered,  and 
the  study  of  the  involvement  of  the  cellular  and  muscular  tissues  will 
be  reserved  for  the  chapters  on  Abscess  and  Fistula. 

Owing  to  the  different  anatomical  structures  and  varied  relation 
of  the  parts,  tuberculosis  will  be  described  as  seen  in  the  'perianal  re- 
gion, the  anal  canal,  the  rectum,  and  the  pelvic  colon. 

PERIANAL   TUBERCULOSIS 

In  the  skin  about  the  anus,  rich  in  hair  follicles,  sebaceous  and 
sudoriparous  glands,  foci  of  tubercle  bacilli  often  lodge  and  develop 
most  destructive  processes.  They  are  divided  into  miliary,  ulcerative, 
lupoid,  and  papillary  or  verrucous  tuberculosis. 

Miliary  Variety. — This  type  of  the  disease  is  very  rare;  it  is  seen 
almost  entirely  in  cases  afPected  with  tuberculosis  of  other  organs,  and 
is  said  by  Chiari  to  occur  almost  exclusively  at  the  muco-cutaneous  mar- 
gins; the  author  has  seen  it  well  outside  of  this  area  in  the  perianal 
skin. 

13  193 


194  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

It  develops  as  minute  nodules  or  infiltrations  which  feel  like  small 
shot  or  millet-seeds  beneath  the  epidermis.  They  are  always  multiple, 
and  grouped  in  crescentic  or  circular  shape.  They  develop  in  the  glands 
of  the  skin,  and  gradually  grow  larger  imtil  pressure  upon  the  over- 
lying epithelium  causes  necrosis,  and  it  falls,  leaving  shallow,  cup-shaped 
ulcers  with  ragged,  indurated  borders.  Small  miliary  nodules  may  be 
seen  covering  the  surface  and  edges  of  these  ulcers.  The}'  discharge  a 
scant  amount  of  sero-pus  and  do  not  bleed  on  touch.  They  are  more 
painful  than  most  tubercular  processes.  As  a  rule,  they  remain  station- 
ary until  the  patient  succumbs  to  the  pulmonary  affection,  but  they  may 
spread,  coalesce,  and  form  extensive  ulcers.  Observations  as  to  the 
histology  of  the  surrounding  tissues  have  not  been  made,  but  numer- 
ous tubercle  bacilli  were  found  in  scrapings  from  the  ulcers. 

Treatment. — This  local  condition  is  so  rare  and  of  so  little  impor- 
tance compared  with  the  intestinal  and  pulmonary  lesions  which  accom- 
pany it  that  no  one  has  formulated  any  treatment  for  it.  The  appli- 
cation of  the  galvano-cautery  or  X  ray  might  destroy  the  bacilli  and 
cause  healing,  but  the  general  constitutional  condition  is  the  chief  factor 
in  the  case,  and  all  effort  should  be  bent  to  remedy  this. 

Change  of  climate,  creosote,  cod-liver  oil,  hypophosphites,  forced 
feeding,  and  all  the  hygienic  measures  adopted  in  general  tuberculosis 
should  be  employed;  but  after  all,  nothing  that  is  known  at  present 
can  enable  one  to  give  a  favorable  prognosis  in  such  cases. 

TJlcerative  Variety. — All  tubercular  processes  of  the  superficial  tegu- 
ments arrive  sooner  or  later  at  an  iilcerative  stage.  The  characters  of 
these  ulcers  differ  according  to  the  tissues  involved  and  the  constitu- 
tional condition  of  the  patient. 

Simple  tubercular  ulcers  of  the  anus  begin  in  an  obscure  manner. 
They  may  develop  from  contusions,  wounds,  and  injuries,  or  they  may 
be  idiopathic. 

The  patient  generally  has  a  history  of  tuberculosis  either  hereditar}'' 
or  acquired,  but  there  may  be  no  marked  localization  of  the  disease. 
A  small  induration  or  nodule  occurs  in  the  superficial  layers  of  the  skin. 
Traumatism,  friction,  or  injury  may  cause  a  breaking  down  of  the  tis- 
sues, and  ulceration  results.  This  may  be  brought  about  by  an  attack 
of  diarrhoea,  a  horseback  or  bicycle  ride,  or  a  thrombotic  haemorrhoid. 
It  may  start  in  the  anal  canal  or  in  the  skin  itself  around  the  anus;  it 
may  be  confined  to  the  latter  tegument,  or  it  may  be  limited  to  the 
anal  canal. 

As  to  the  comparative  frequency  with  which  it  attacks  the  two  por- 
tions of  the  anus,  it  is  difficult  to  decide.  In  nearly  all  of  those  cases 
which  the  author  has  observed,  the  ulceration  has  at  one  time  or  another 
involved  both  the  perianal  tissues  and  the  anal  canal,    Hartmann,  in  his 


TUBERCULOSIS  OP  THE  ANUS,  RECTUM,  AND  PELVIC  COLON    195 


exhaustive  studies  upon  this  subject,  states  that  he  has  four  times  seen 
these  ulcerations  almost  entirely  surround  the  anus,  destroying  all  the 
cutaneous  tissues  with  the  exception  of  a  small  bridge  of  skin  which 
was  left  intact  without  involving  the  anal  canal.  They  may  develop 
singly  and  spread  to  both  sides  of  the  anus,  or  several  ulcers  may  develop 
at  one  time  and  coalesce  to  form  one  large,  irregular  ulcer  (Fig.  89). 
They  are  irregularly  round,  the  edges  rdore  or  less  ragged,  and  they  tend 
to  spread  circularly  and  upward  into  the  anal  canal  at  the  same  time. 

The  borders  are  clear- 
cut,  undermined,  with  a 
pale  sloughing  edge,  which 
fades  oif  into  a  rose-col- 
ored border  in  the  skin. 
There  is  an  induration  or 
hypertrophy  around  the 
margin;  the  base  of  the 
ulcer  is  irregular,  grayish 
in  color,  and  presents  a 
sort  of  elevation  in  the 
center,  with  a  depression 
around  the  edges  beneath 
the  undermined  skin 
(Plate  II,  Fig.  3). 

The  granulations  are 
pale,  do  not  bleed  easily, 
and  are  of  very  unequal 
sizes.  Here  and  there 
scattered  over  the  ulcers 
are  small  yellowish  pim- 
ples or  tubercles  which 
seem  to  be  embedded  in 

the  tissue.  These  may  be  picked  out  with  a  needle  or  a  sharp  spoon, 
but  they  do  not  come  away  with  gentle  wiping  or  irrigation.  When 
they  are  picked  out  they  will  leave  a  sort  of  cavity,  smooth  and  shining, 
and  about  the  size  of  Ko.  8  bird-shot.  Hartmann  stated  that  the  surface 
of  these  ulcers  was  always  soft  and  supple  except  in  two  cases.  The 
author  has  excised  a  number  of  them,  and  has  yet  to  find  one  in  which 
there  was  not  an  induration  beneath  the  area  involved;  he  has  found 
in  the  scrapings  tubercle  bacilli,  thus  proving  their  nature;  and  be- 
neath the  granulating  tissues  of  the  ulcers  there  was  a  smooth,  glistening 
tissue  that  showed  a  fibrous  alteration  of  the  teguments  beneath,  or, 
in  fact,  a  real  cicatricial  development,  in  which  no  tubercle  could  be 
found. 


Fig. 


-Perianal   Tubeeculae   Ulceu   suEEOUKBiNa 
External  Opening  of  a  Fistula. 


196  THE  ANUS,  KECTUM,  AND   PELVIC  COLON 

Pain  is  not  a  marked  symptom.  Ordinarily  the  patient  suffers  very 
little  even  from  fsecal  passages  or  the  direct  handling  of  the  parts.  Oc- 
casionally, however,  when  the  ulceration  invades  the  anal  canal  and 
assumes  the  form  of  fissure,  the  pains  become  more  severe  at  the  time 
of  defecation.  As  a  rule,  however,  tubercular  ulcerations  of  the  anal 
canal  and  its  margin  are  both  comparatively  free  from  pain.  Al- 
most without  exception  has  this  been  the  case  in  the  large  number  of 
tubercular  ulcerations  of  the  anus  seen  in  consumptive  patients  in  the 
hospital  on  Blackwell's  Island.  In  two  cases  in  which  the  ulcers  were 
excised,  previous  to  the  operation  and  immediately  thereafter  the  pa- 
tients suffered  no  pain  whatever ;  but  when  the  wound  had  almost  healed, 
and  there  remained  only  a  small  granulation  at  the  margin  of  the  anus, 
they  began  to  complain  of  sphincteric  spasm  and  pain  following  the 
faecal  movements. 

In  another  case,  in  which  a  tubercular  ulceration  was  cauterized  with 
the  Paquelin  cautery,  there  was  no  pain  previous  to  it,  nor  after  the 
first  cauterization ;  but  after  the  second,  when  the  discharge  had  almost 
ceased  and  the  ulceration  was  apparently  healing,  the  patient  suffered 
more  or  less  acute  pain  after  fsecal  movements.  At  this  time,  examina- 
tion of  the  slight  discharge,  and  also  the  scrapings  of  the  ulcers,  failed 
to  demonstrate  the  presence  of  any  tubercle  bacilli.  The  tubercular 
process  was  afterward  reestablished  in  this  wound,  and  it  became  again 
painless  to  the  touch.  It  is  difficult  to  understand  why  these  ulcerations 
are  not  painful.  There  is  the  inflammatory  element,  the  development  of 
fibrous  tissue,  the  involvement  of  the  sensitive  nerve  areas — in  fact, 
every  element  necessary  to  account  for  the  production  of  pain,  but  no 
satisfactory  explanation  of  its  absence  has  been  offered. 

The  discharge  from  these  ulcers  is  generally  limited,  of  a  thin  puru- 
lent character,  and  very  rarely  tinged  with  blood.  Sometimes  there 
may  be  a  mixed  infection,  and  the  quantity  of  the  discharge  is  materially 
increased. 

When  this  type  of  ulcer  extends  into  the  anal  canal  it  does  not 
usually  assume  the  form  of  fissure,  as  do  most  other  ulcers,  but  seems 
to  spread  over  the  radial  folds  and  down  into  the  sulci  at  the  same 
time.  It  is  usually  limited  by  the  "  white  line  "  of  Hilton,  but  may 
extend  upward  to  the  border  of  the  sphincter,  and  end  in  a  clear-cut 
margin,  somewhat  indurated,  with  a  perfectly  healthy  mucous  membrane 
just  above  it. 

The  progress  of  tubercular  ulceration  around  the  anus  is  vari- 
able. Sometimes  it  is  very  slow,  while  at  others  it  is  rapid  and  de- 
structive in  the  highest  degree.  Contrary  to  the  history  of  syphilitic 
ulcers,  there  is  no  tendency  to  heal  in  one  part  while  they  progress  in 
another.    A  tubercular  ulcer  in  the  absence  of  treatment  shows  but  one 


TUBERCULOSIS   OF  THE  AXUS,   RECTUM,   AND   PELVIC   COLON    197 

tendency,  and  that  is  to  progress  in  all  directions;  under  general  con- 
stitutional and  local  treatment  it  may  be  healed,  but  if  left  alone  its 
on^vard  march  is  stopped  only  by  death;  it  is  not,  as  a  rule,  fatal  in 
itself,  but  it  remains  as  a  disturbing  element  until  the  end  comes 
through  development  of  other  tubercular  lesions  or  some  form  of  in- 
tercurrent disease;  ordinarily  it  is  acute  pulmonary  or  genito-urinary 
tuberculosis. 

ANAL  TUBERCULOSIS 

Tuberculosis  may  attack  the  anal  canal  either  by  extension  from 
the  perianal  region  or  j^rimarily.  Indeed^  it  is  often  a  question  whether 
the  disease  originates  in  the  perianal  or  intra-anal  tissues.  In  the 
anal  canal  the  miliary  or  nodular  type  is  rarely  observed,  but  the  ulcer- 
ative form  is  very  common.  It  assumes  the  shape  of  fissure  simply 
on  account  of  the  conformation  of  the  parts,  the  overlying  membranes 
being  corrugated  or  compressed  into  folds  by  the  contraction  of  the 
sphincter.  It  does  not  long  remain  confined  to  the  sulci,  but  rapidly 
extends  toward  the  cutaneous  margin  and  upward  upon  the  radial  folds, 
sometimes  crossing  over  from  one  sulcus  to  another,  entirely  destroying 
the  muco-cutaneous  covering. 

The  ulcers  may  be  single  or  multiple.  In  the  latter  case  they  soon 
coalesce  to  form  one  ulcer  which  may  entirely  surround  the  canal.  They 
are  distinguished  by  their  clear-cut  though  irregular  borders,  their 
grayish-yellow  bases,  with  here  and  there  round  tubercles  in  the  granu- 
lar mass,  and  by  the  little  foci  of  disease  that  extend  into  the  subcu- 
taneous tissues  like  worm-holes  in  wood,  and  sometimes  result  in  sub- 
tegumentary  fistulas  (Plate  II,  Fig.  1). 

The  absence  of  pain  in  any  marked  degree  is  the  most  characteristic 
feature  of  the  intra-anal  tubercular  ulceration.  All  other  forms  may, 
under  certain  circumstances,  produce  acute,  lasting  pain,  resembling 
true  irritable  ulcer,  but  with  the  tubercular  ulceration  this  almost  never 
occurs.  It  is  true  that  tuberculosis  may  be  ingrafted  upon  an  irritable 
ulcer,  and  we  may  have  the  two  conditions  combined  in  the  same 
anus,  but  under  such  circumstances  one  will  have  the  history  of  lively 
pains  and  spasm  of  the  sphincter  having  existed  for  a  period  entirely 
too  long  for  the  tubercular  ulceration  to  have  remained  so  limited  in 
extent.  Had  the  lesion  been  tubercular  at  the  beginning  there  would 
have  been  greater  destruction  of  tissue  than  is  seen  in  such  mixed  cases. 
Chancres,  mucous  patches,  and  rodent  ulcers  of  the  anus  are  all  much 
more  painful  than  the  tubercular  variety.  The  explanation  of  this  fact 
may  lie  in  the  relaxation  of  the  muscles,  or  it  may  be  due  to  the  fact 
that  beneath  and  around  the  tubercular  ulceration  there  is  always  formed 
a  connective-tissue  envelope  or  waU  which  is  not  thick,  but  which  pro- 


198  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

tects  the  deeper  tissues  from  infection  by  the  pathogenic  process  and 
thus  avoids  the  involvement  of  the  sensitive  nerve  roots  in  a  process  of 
perineuritis  associated  with  muscular  contraction.  Involvement  of  the 
lungs  and  other  organs  is  much  more  frequent  in  tuberculosis  of  the 
anal  canal  than  in  that  of  the  perianal  region.  The  higher  the  involve- 
ment of  the  intestinal  canal,  the  greater  is  the  probability  of  general 
tuberculosis. 

Pathological  Anatomy. — The  pathological  examination  of  these 
ulcers  shows  always  upon  the  cutaneous  border  degeneration  of  the 
corneous  layer  of  the  epithelium.  There  is  hypertrophy  of  the  papillary 
layer  and  great  infiltration  of  the  chorion,  which  dips  well  down  into  the 
deeper  layers  of  the  derma.  The  granular  stratum  is  depressed  by  the 
inflammatory  processes.  The  Malpighian  bodies  are  sometimes  hyper- 
trophied  or  swollen,  sometimes  absent.  The  blood-vessels  present  evi- 
dences of  tuberculosis  in  the  thickened  and  fibrous  condition  of  their 
walls.  The  papillae,  hypertrophied  and  infiltrated,  compose  the  fleshy 
granulations,  and  by  their  conglomeration  produce  the  caseous  follicles. 
These  fleshy  granulations  appear  rough  and  elevated  in  spots,  but  do 
not  have  deep  sulci  dipping  down  between  them,  as  in  condylomata.  As 
Hartmann  says :  "  In  these  masses  there  exists  a  number  of  caseous 
tracts  which  start  out,  in  general,  perpendicularly  to  the  surface  of  the 
ulceration.  These  tracts,  which  open  probably  by  small  mouths  upon 
the  surface,  are  lined  with  epithelial  cells,  and  result  from  the  fusion 
of  a  large  number  of  tuberculous  follicles,  as  is  proved  by  a  certain  num- 
ber of  isolated  follicles."  My  examinations  have  not  demonstrated  these 
facts,  but  we  must  accept  the  reports  of  such  careful  work  as  has  been 
done  by  the  authors  quoted  (Chir.  d.  rect.,  vol.  i,  p.  124). 

The  most  important  element  in  these  pathological  examinations, 
however,  is  the  cicatricial  or  fibrous  layer  which  develops  in  the  deepest 
tissues  down  below  these  tracts  and  outside  of  the  area  in  which  the 
tubercles  are  found.  This  material  not  only  involves  the  smooth  and 
striated  muscular  fibers,  but  also  the  blood-vessels  and  the  nerves;  the 
latter  are  included  in  sheaths  of  embryonic  cells  and  a  sclerotic  tissue 
similar  to  that  developed  in  the  muscle.  In  this  portion  of  the  ulcera- 
tion we  have  to  deal  with  a  purely  inflammatory  process  which  forms  a 
sort  of  wall  around  the  tubercular  focus,  thus  obstructing  the  invasion 
of  the  surrounding  healthy  tissues  by  the  tubercle  bacilli. 

The  rationale  of  this  is  shown  in  the  fact  that  where  a  cicatrix  exists, 
the  disease  does  not  progress  beyond  it.  Cicatricial  tissue  is  an  absolute 
barrier  to  the  extension  of  tubercular  processes.  A  tubercular  ulcer  may 
involve  the  whole  circumference  of  the  anus  and  never  dip  deeper  down 
than  the  derma,  because  this  wall  of  connective  tissue  is  formed  at  its 
base.     Quenu  relates  a  case  in  which  the  ulceration  developed  near  the 


PLATE    II. 


1.  TUBERCULAR   ULCERATION   WITH    FISTULA 


3.   SUPERFICIAL  TUBERCULAR  ULCERATION 


ANAL  TUBERCULOSIS 


TUBERCULOSIS  OP  THE  ANUS,  RECTUM,  AND  PELVIC  COLON    199 

site  of  an  old  fistulous  tract,  and  states  as  a  very  interesting  experi- 
ence that  the  ulceration  never  crossed  or  broke  down  the  cicatrix  left  by 
the  old  operation.  His  experience  is  by  no  means  unique.  It  is  easily 
explained  by  the  facts  that  cicatricial  tissue  is  almost  devoid  of  blood- 
vessels, and  is  absolutely  free  from  lymphatics,  and  the  progress  of  the 
tubercle  is  always  along  one  of  these  lines.  This  is  the  most  important 
discovery  with  regard  to  tubercular  ulcers  in  recent  years,  second  only 
to  that  of  the  bacillus,  and  it  forms  the  basis  of  all  local  treatment. 

Fatty  degeneration  of  these  ulcers  is  a  very  rare  occurrence.  In- 
volvement of  the  lymphatic  glands  occurs,  if  at  all,  early  in  the  process. 
Pulmonary  or  genito-urinary  tuberculosis  may  develop  from  the  disease 
in  the  anus,  but  usually  they  precede  the  latter. 

Treatment. — In  the  large  majority  of  cases  the  local  lesion  is  a 
minor  consideration  compared  to  the  probable  constitutional  involve- 
ment. The  healing  of  the  sore  depends  upon  the  power  of  resistance 
in  the  tissues,  and  the  better  the  physical  condition  of  the  patient  the 
greater  will  be  this  power.  All  treatment,  therefore,  which  depresses  the 
vital  forces,  which  decreases  the  tone  of  the  tissues  in  general,  or  which 
interferes  with  the  free  and  full  oxidation  of  the  blood  will  be  detri- 
mental in  the  management  of  these  cases.  Thus,  extensive  operations 
which  confine  the  patient  to  bed  or  even  to  the  house  are  unadvisable. 
Prolonged  local  treatment^  which  requires  the  patient  to  remain  in 
large  centers  of  population,  or  to  be  confined  in  hospital  wards,  is  not 
likely  to  prove  successful.-  Change  of  climate,  outdoor  exercise,  forced 
feeding  with  fats  and  hydrocarbons,  together  with  massage  and  oil  in- 
unctions, will  do  more  for  these  conditions  than  local  treatment  or  sur- 
gical operations;  at  the  same  time  the  latter  need  not  be  neglected. 

The  parts  should  be  kept  clean  by  bathing  with  peroxide  of  hydro- 
gen, solutions  of  bichloride  of  mercury,  or  other  antiseptics.  If  the 
ulceration  is  extensive,  a  gauze  dressing  moistened  with  one  of  these 
solutions  should  be  kept  applied.  Painting  the  ulcer  with  a  solution  of 
methylene  blue,  10  grains  to  the  ounce,  seems  to  have  a  good  effect,  and 
can  be  carried  out  by  the  patient  himself.  As  a  rule,  powders  seem  to 
make  these  ulcers  worse,  but  recently  some  very  good  results  have  fol- 
lowed the  application  of  orthoform.  In  one  case  a  large  tubercular 
ulcer,  involving  almost  the  entire  anus  and  dipping  well  into  the 
ischio-rectal  fossa  and  the  perineal  triangles,  has  almost  completely 
healed  under  the  combined  use  of  this  drug  and  the  methylene-blue 
applications.  The  same  ulcer  grew  steadily  worse  during  treatment  by 
the  actual  cautery  and  many  other  methods  ordinarily  advised. 

Eecently  the  Eoentgen  rays  have  been  recommended  for  these  cases, 
but  nothing  definite  is  known  as  to  the  results  of  this  treatment.  The 
occasional  application  of  the  actual  cautery,  together  with  the  local 


200  THE  ANUS,  RECTUM,  AND  PEL^aC  COLON 

and  hygienic  measures  indicated  above,  appear  to  be  the  most  reliable 
methods.  The  cases  treated  b}'  orthoform  and  methylene  bine,  up  to 
the  present  writing,  are  too  few  to  justify  one  in  recommending  the 
method  unreservedly;  it  appears,  however,  to  be  worthy  of  further  trial. 

Lupoid  Ulceration  of  the  Anus. — For  a  long  time  it  was  believed  that 
lupus  was  a  specific  variety  of  ulcer.  Eecent  studies  in  pathology,  how- 
ever, have  shown  it  to  be  only  one  of  the  many  manifestations  of  tuber- 
culosis. It  is  of  a  particularly  aggravated  form,  slow  in  its  march,  yet 
fearfully  destructive  of  tissues. 

Under  the  title  Esthiomene  and  Lupus  Exedens  this  condition  has 
been  described  with  great  detail  by  E.  W.  Taylor  (Xew  York  ]\Iedi- 
cal  Journal,  January  4,  1890).  His  conclusions  at  that  time  were  that 
the  condition  is  a  syphilitic  manifestation.  This  view,  however,  has 
been  abandoned,  and  we  now  come  to  recognize  in  lupus  only  another 
form  of  tuberculosis.  Those  who  formerly  held  that  the  condition  was 
syphilitic  advance  the  theory  that  the  peculiar  course  of  the  ulceration 
was  due  to  inoculation  of  tubercular  or  scrofulous  individuals  with 
syphilis.  Were  the  ulceration  of  a  syphilitic  nature,  as  has  been  held 
by  these  writers,  constitutional  treatment  would  have  modified  its  course, 
checked  its  advances,  and  prevented  its  recurrence,  but  such  is  not  the 
case.  Upon  these  ulcerations  syphilitic  medication  has  no  effect  what- 
ever. 

The  condition  is  characterized  by  progressive  ulcerative  destruction. 
Ordinarily  it  begins  at  the  muco-cutaneous  margin  either  of  the  anus  or 
the  vulva.  The  outline  of  the  ulcer  is  irregular,  clear-cut,  and  indurated. 
One  sees  at  times  a  slight  tendency  to  cicatrize  at  certain  points,  but 
after  a  short  time  these  cicatrizations  break  down,  reulcerate,  and  spread 
farther  in  the  tissues.  Taylor  does  not  state  what  was  the  final  result 
in  the  cases  which  he  saw,  but  of  the  5  cases  reported  by  Allingham, 
3  certainly,  and  probably  5,  finall}^  succumbed  to  tuberculosis.  Be- 
neath the  ulcers  there  is  always  the  development  of  fibrous  infiltra- 
tion identical  with  that  which  we  have  described  beneath  the  sim- 
ple tubercular  ulceration,  and  through  which  the  destruction  of  tissue 
does  not  break  until  very  late  in  the  disease.  Upon  this  point  Kelsey 
says,  in  recounting  an  interesting  case  upon  which  he  operated  and 
tried  to  remove  the  ulcerated  condition  by  scraping  and  cauteriza- 
tion :  "  I  was  surprised  to  find  it  impossible  to  reach  healthy  tissue  below 
the  ulcer  without  removal  of  an  immense  mass  of  inflammatory  thick- 
ening. There  seemed  to  be  no  healthy  connective  tissue  near  the  sores, 
but  simply  a  brawny,  honeycombed  condition,  resembling,  after  scraping, 
a  mass  of  hard  cheese,  with  a  network  of  connective-tissue  fibers  run- 
ning through  it." 

The  spaces  between  these  fibers  were  undoubtedly  due  to  fatt^^  de- 


TUBERCULOSIS  OF   THE  ANUS,  RECTUM,  AND  PELVIC   COLON    201 

generation  of  the  muscular  fibers  and  tubercular  invasion  of  the  lym- 
phatics and  cellular  tissue.  In  this  same  case  specific  treatment  was 
carried  to  its  full  extent,  but  without  effect,  and  the  patient  finally  died 
from  exhaustion.  The  extent  to  which  this  form  of  ulceration  may 
proceed  is  exemplified  in  the  following  case  reported  by  Angus  Mc- 
Donald (Edinburgh  Medical  Journal,  1884,  p.  910): 

Quoting  Duncan's  description  of  the  case,  he  says : 

" '  A  case  to  which  I  was  called  some  years  ago  is,  so  far  as  I  know, 
so  unprecedented  in  the  amount  of  destruction  as  to  be  worth  describ- 
ing. I  only  saw  it  once  in  consultation.  The  disease  was  at  one  time 
regarded  as  cancerous.  The  patient,  aged  about  forty,  had  had  the 
disease  for  at  least  five  years,  and  she  lived  many  years  after  my  visit. 
While  the  disease  was  already  extensive  she  bore  a  child.  On  the  hips, 
just  beyond  the  ischial  tuberosities,  were  long  scars,  thin  and  bluish,  of 
healed  ulcers.  The  entire  ano-perineal  region  was  gone,  there  being 
a  hollow  space  as  big  as  a  foetal  head.  The  urethra  was  entire,  as  well 
as  the  mucous  membrane  between  it  and  the  cervix  uteri,  which  was 
healthy.  Except  the  anterior  portion  of  the  vagina,  no  trace  of  it,  or  of 
the  anus  or  rectum,  was  discoverable ;  behind  the  cervix  uteri  the  bowel 
opened  by  a  tight  aperture,  just  sufficient  to  admit  a  finger;  when  the 
fasces  were  hard  she  could  keep  herself  clean,  but  only  then.  Although 
the  extent  of  ulceration  was  severe  the  patient  was  attending  to  her 
household  duties.'  To  this  graphic  description  of  the  case  I  can  fully 
subscribe,  with  this  addition,  that  latterly  the  ulceration  went  still 
higher  up  into  the  pelvis,  leaving  the  bowel  hanging  loose  for  some 
distance  from  the  upper  level  of  ulceration,  giving  it  the  appearance  of 
the  torn  sleeve  of  a  coat.  This  patient  lived  two  and  a  half  years 
after  the  time  referred  to  by  Dr.  Duncan,  and  died  of  exhaustion  and 
diarrhoea.  Notwithstanding  this  shocking  amount  and  prolonged  con- 
tinuance of  ulcerative  action,  there  was  no  involvement  of  inguinal 
or  other  glands." 

Allingham,  Ball,  and  others  have  seen  cases  similar  to  this,  but  less 
extensive.  Bender  (Vierteljahr.  f.  Derm.  u.  Syph.,  Wien,  1888,  p.  891) 
describes  one  in  which  a  large  portion  of  the  rectum  was  involved.  Ordi- 
narily, however,  the  ulceration  is  limited  to  the  cutaneous  and  muco- 
cutaneous tissues. 

Generally  the  ulcer  begins  in  one  or  more  little  circular  or  semi- 
circular infiltrations  in  the  skin  or  muco-cutaneous  tissue  about  the 
anus.  These  break  down,  ulcerate,  and,  spreading  at  their  borders, 
the  little  foci  coalesce  and  form  larger  ulcers.  The  edges  are  sharp- 
cut  and  not  so  much  undermined  as  in  simple  tubercular  ulcerations. 
In  one  respect  it  seems  to  differ  entirely  from  these,  in  that  it  has  a 
tendency  to  heal  temporarily  and  produce  cicatrization  in  certain  areas ; 


202  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

but  this  only  lasts  for  brief  periods,  when  it  breaks  down  again,  and  the 
destruction  of  tissue  advances  beyond  the  original  limitations.  Some- 
times the  ulcerations  may  take  on  a  serpiginous  form,  advancing  in 
two  or  more  narrow  tracts.  After  a  time  the  intervening  tissue  be- 
tween these  tracts  gradually  breaks  down,  and  the  whole  area  becomes 
a  part  of  the  original  ulceration.  The  edges  of  these  ulcers  are  never 
thickened  or  indurated  to  any  great  extent.  The  granulations  are 
generally  pale,  although  occasionally  they  may  be  bright  red  and  ex- 
uberant. Bender  describes  them  as  a  reddish-brown,  and  sometimes  of 
an  efflorescent  type.  The  base  of  the  ulcer  itself  is  soft,  but  the  under- 
lying inflammatory  deposit  gives  to  it  a  stiff,  inelastic  feel  upon  firm 
pressure. 

The  pathological  examinations  of  these  cases  made  by  Besnier  and 
Schuchardt  place  the  tuberculous  nature  of  the  ulcers  beyond  doubt. 

In  one  case  seen  in  the  city  almshouse,  a  man,  aged  seventy-four, 
had  suffered  from  ulceration  about  his  rectum  for  a  number  of  years. 
It  never  gave  him  any  particular  pain,  and  only  required  the  wearing 
of  a  cloth  to  protect  his  clothing.  When  seen  by  the  writer  it  had  be- 
come somewhat  difficult  to  move  his  bowels  or  to  walk.  Examination 
showed  a  vast  ulcerated  area  involving  the  entire  circumference  of  the 
anus,  and  extending  as  high  up  as  the  upper  border  of  the  external 
sphincter.  The  skin  for  2  inches  around  the  entire  anus  was  destroyed, 
and  the  ulceration  dipped  down  into  the  cellular  tissues  posteriorly  and 
at  the  sides  of  the  rectum  to  a  depth  of  -J  an  inch  or  more.  The  mar- 
gins of  the  ulceration  were  not  indurated  but  slightly  undermined. 
There  were  at  points  in  its  circumference  evidences  of  attempts  at 
cicatrization,  but  there  was  no  contraction  or  apparent  diminution  in 
the  size  of  the  ulcers  from  these  efforts  at  healing.  The  granulations 
were  not  exuberant  or  efflorescent  at  any  point,  but  were  more  of  a 
grayish-brown,  proud-flesh  nature.  Beneath  these  granulations  there 
was  a  hard  resisting  base  which  extended  outside  the  margin  of  the 
ulceration  and  upward  until  it  joined  the  wall  of  the  gut.  At  the  upper 
margin  of  the  ulceration  the  mucous  membrane  of  the  rectum,  clear-cut, 
infiltrated,  and  somewhat  elevated,  seemed  absolutely  to  limit  the  in- 
vasion of  the  disease,  and  was  perfectly  healthy  at  a  distance  of  one  or 
two  lines  above. 

The  patient  had  pulmonary  tuberculosis  at  the  time,  and  was  taken 
from  the  hospital  shortly  afterward  to  a  home  in  the  country,  where, 
it  was  since  learned^  he  died  from  the  disease. 

The  area  of  ulceration  from  side  to  side  measured  5^  inches,  from 
before  backward  2^  inches,  and  the  depth  from  the  margin  of  the  anus 
upward  behind  the  rectum  was  about  ^  an  inch. 

There  appears  to  be  quite  a  difference  of  opinion  between  Ailing- 


TUBERCULOSIS   OF   THE  ANUS,  RECTUM,  AND   PELVIC   COLON    203 

ham  and  other  observers  concerning  the  clinical  appearance  of  lupoid 
ulceration,  its  location,  and  the  nature  of  its  invasion.  The  former  holds 
that  it  occurs  in  the  rectum,  and  its  tendency  is  to  attack  the  mucous 
membrane  rather  than  the  skin;  that  it  does  not  invade  the  neighbor- 
ing tissues  by  infiltration  or  through  the  lymphatics,  forms  no  sec- 
ondary deposits,  produces  no  hardness,  and  does  not  affect  the  follicles. 
He  states  that  the  diagnosis  can  be  positively  made  on  sight. 

Others  (Ball,  Cripps,  Kelsey,  Gant,  Taylor,  and  Quenu)  state  that 
it  is  generally  found  in  connection  with  the  disease  in  the  female  geni- 
tals, and  is  largely  confined  to  the  skin  and  muco-cutaneous  membrane; 
that  there  is  induration  about  the  base  and  edges;  that  microscopic 
examination  establishing  the  presence  of  tubercle  bacilli  or  giant  cells 
is  necessary  to  distinguish  it  from  epithelioma  and  syphilitic  ulceration, 
and  that  it  does  extend  along  the  lymphatics. 

All  agree  that  it  is  essentially  a  destructive  lesion  and  of  a  tubercular 
nature,  with  clean-cut,  irregular,  rarely  symmetrical  edges  that  may  or 
may  not  be  undermined. 

The  writer  has  observed  two  cases  almost  from  their  incipiency. 
Both  were  in  males,  and  began  in  the  skin  at  the  anal  margin.  One 
developed  around  the  cicatrix  of  an  old  fistula,  as  in  the  cases  of  Schuch- 
ardt  and  Besnier,  and  the  other  in  a  skin-tab  just  below  a  fissure. 
Both  started  as  little  nodules  or  indurated  masses  in  the  skin.  These 
seemed  to  have  no  relation  to  the  hair  follicles,  but  in  one  case  appeared 
like  obstructed  sebaceous  glands.  The  nodules  in  each  case  broke  down, 
discharged  a  sort  of  cheesy  pus,  and  left  round,  clear-cut  ulcers.  These 
soon  coalesced  and  formed  one  large  ulcer,  which  slowly  but  steadily 
extended  around  the  anus  and  into  the  anal  canal.  In  one  case  the 
process  involved  the  mucous  membrane  to  the  height  of  ^  an  inch,  in 
the  other  it  stopped  abruptly  at  the  ano-rectal  line.  In  the  fistula  case 
the  cicatrix  seemed  to  limit  its  extent  in  one  direction,  so  that  only 
half  of  the  circumference  of  the  anus  was  involved.  In  the  other  the 
disease  spread  all  round  the  aperture  (Plate  II,  Fig.  2).  In  both  cases 
there  soon  developed  a  fibrous  or  cicatricial  deposit  beneath  the  ulcera- 
tion, which  extended  almost  to  the  healthy  skin  outside  of  it.  This 
mass  was  penetrated  here  and  there  by  small,  soft  spots  due  to  fatty 
degeneration  of  the  muscular  fibers. 

The  ulcerations  were  irregular  in  shape,  with  well-defined,  indu- 
rated borders  slightly  undermined.  The  bases  were  brownish-gray,  de- 
•pressed,  and  covered  with  scant,  purulent  secretion.  There  was  prac- 
tically no  pain  in  either  case. 

Histological  examination  of  the  scrapings  showed  tubercle  bacilli 
present  in  both  cases.  The  extension  seemed  uniform  and  not  in  the 
lines  of  any  vessels  or  lymphatics.     Time  and  again  in  both  cases  the 


204  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

parts  appeared  to  be  healing  and  then  broke  down  again,  leaving  the 
ulcer  deeper  and  more  extensive  than  before.  In  neither  case  were 
bright-red  or  efflorescent  granulations,  as  described  by  Bender,  seen 
except  in  very  small  spots.     The  ulcers  did  not  bleed  easily  on  touch. 

Treatment. — The  usual  treatment  of  this  condition  consists  in  the 
application  of  chemical  or  actual  cauterization.  Nitric  acid,  chloride  of 
zinc,  acid  nitrate  of  mercury,  etc.,  have  been  advised,  as  have  also  the 
Paquelin  and  galvano-cautery.  "Where  there  is  pain  this  will  be  some- 
what relieved  for  a  time  by  such  applications,  but  the  benefit  is  only 
temporary.  According  to  Piffard,  the  application  of  strong  solutions 
of  peroxide  of  hydrogen  used  every  few  days  seems  to  be  more  effectual 
in  the  destruction  of  the  tubercle  bacilli  and  the  development  of  healthy 
granulations  than  any  of  the  other  chemical  agents.  It  may  be  well 
in  the  beginning  of  the  treatment  to  cauterize  the  parts  thoroughly 
by  the  Pacjuelin  cautery,  but  one  must  always  remember  that  the  con- 
stitutional condition  of  the  patient  suffering  from  this  form  of  disease 
is  not  such  as  to  justify  any  great  shock  or  destruction  of  tissue,  and 
that  the  lack  of  vitality  in  the  parts  may  cause  such  a  burn  to  result 
in  extensive  slough,  and  thus  do  more  harm  than  good.  While  actual 
cauterization  is  superior  to  chemical,  or  excision,  or  curetting  in  these 
conditions,  the  author  can  not  but  sound  a  note  of  warning  in  view  of 
the  experience  which  he  saw  some  three  years  ago  in  the  New  York 
workhouse. 

A  young  man  having  an  extensive  lupoid  ulceration  about  the  mar- 
gin of  the  anus,  which  the  attending  surgeon  looked  upon  as  chancroidal, 
was  etherized  and  the  ulceration  excised,  the  base  being  thoroughly 
burned  with  a  Pacpielin  cautery.  The  patient  suffered  extremely  from 
shock.  There  was  great  sloughing  of  the  tissues,  so  much  indeed  that 
the  whole  external  sphincter  and  lower  inch  of  the  rectum  for  one-half 
of  its  circumference  were  destroyed.  The  patient  suffered  from  incon- 
tinence, and  within  a  few  weeks  developed  acute  tuberculosis,  from 
which  he  died  in  about  five  months.  The  examination  of  the  specimen 
showed  typical  characteristics  of  tubercular  ulceration.  Conservatism, 
therefore,  is  of  the  greatest  importance  in  the  treatment  of  these  ulcers. 

Methylene  blue,  2  per  cent  in  water,  has  held  the  disease  in  check 
better  than  anv  other  remedy  in  my  hands,  but  nothing  has  cured  it. 
Electrolysis  and  the  X  ray  have  been  recommended,  and  recent  reports 
seem  to  confirm  its  usefulness;  tuberculin  has  been  tried,  but  in  vain. 

Curettage,  followed  by  the  X  ray,  together  with  general  constitu- 
tional treatment  by  tonics,  cod-liver  oil,  creosote,  and  forced  feeding, 
appears  to  give  the  most  uniform  results. 

Verrucous  Ulcerations  of  the  Anus. — A  very  rare  variety  of  ulcera- 
tion of  the  anus  has  been  described  under  the  above  name.     The  first 


TUBERCULOSIS   OF   THE   ANUS,   RECTUM,  AND  PELVIC   COLON     205 

cases  reported  were  by  Toupet  and  Eoutier  (Congres  pour  Tetude  de  la 
tuberculosa,  1893,  p.  509)  in  1893.  At  the  same  congress  M.  Hart- 
maim  reported  two  cases  of  tMs  condition  {ibid.,  p.  59).  It  resem- 
bles epitheliomatous  or  papillomatous  ulcerations  of  the  margin  of  the 
anus.  Judging  from  the  descriptions  given  by  these  authors,  it  would 
appear  to  be  of  the  nature  of  tuberculosis  varicosis  acutis  or  lupus 
papillaris  varicosis,  as  described  in  the  works  upon  dermatology.  In  a 
ease  communicated  by  ]\I.  Duplaix  the  appearances  of  the  ulcers  are 
described  as  follows : 

"  Scattered  around  the  anus  in  places  there  are  small  vegetations 
slightly  jutting  out  above  the  healthy  skin  which  surrounds  them.  In 
places  the  skin,  slightly  ulcerated,  shows  small  columns  separated  one 
from  another,  agglomerated  and  adherent  at  their  bases,  but  free  at 
their  other  end.  There  is  a  mixture  of  small  mammillations  and  of  the 
villous  points.  The  lesion  extends  into  the  anal  canal  and  prolongs 
itself  4  or  5  centimeters  into  the  rectum,  where  one  with  the  finger  is 
able  to  feel  numerous  anfractuosities  separated  by  the  healthy  mucous 
membrane.  The  whole  rests  upon  an  indurated  base,  and  gives  an 
abundant  purulent  secretion,  sometimes  mixed  with  a  little  blood." 
(Quenu  and  Hartmann,  p.  105.)  Hartmann  states  that  in  one  case 
which  he  observed,  the  ulceration  was  in  the  neighborhood  of  a  cold  ab- 
scess of  the  margin  of  the  anus,  and  had  the  appearance  of  a  papilloma. 
The  chief  characteristic  of  these  ulcers  is  their  papillary  or  mammillated 
appearance.  They  may  be  confined  to  the  cutaneous  tissue,  or  they 
may  penetrate  the  anal  canal  and  rectum,  as  in  the  cases  of  Hartmann 
and  Duplaix.  The  villous  formation  sometimes  becomes  crusted  over, 
thus  forming  a  dry  scab,  which  in  a  short  time  comes  away,  leaving  a 
raw,  papillomatous  surface,  the  papillae  being  separated  by  small  bloody 
fissures.  The  base  of  the  ulcer  is  indurated,  but  this  induration  does  not 
extend  into  the  surrounding  tissues.    The  lymphatic  glands  are  enlarged. 

The  tubercular  nature  of  the  ulcers  has  been  verified  by  inoculation 
of  rabbits  and  histological  examination.  In  all  the  cases  in  which  seg- 
ments of  the  ulceration  were  examined,  there  were  found  in  the  super- 
fi.cial  part  of  the  skin  and  in  the  papillary  prolongations  of  the  chorion 
tracts  of  embryonic  cells  containing  giant-cells  and  tubercle  bacilli.  In 
one  case  Hartmann  found  veritable  tuberculous  follicles  with  the  three 
typical  zones  composed  of  giant,  epithelioid,  and  embryonic  cells.  In 
one  case  there  was  a  fistulous  tract  which  extended  6  centimeters  under- 
neath the  skin  and  mucous  membrane. 

The  patients  did  not  complain  of  much  pain  except  in  two  in- 
stances. In  cases  in  which  the  ulceration  invaded  the  rectum  there  was 
a  diarrhoea  accompanied  by  slight  pain  at  the  time  of  defecation.  In 
one  instance  there  was  facal  incontinence.     The  ulceration  appears  in- 


206  THE  ANUS,  RECTUM,  AND  PEL^aC  COLON 

sidiously;  the  patient  notices  only  a  slight  roughness  at  first,  then  a 
swelling  and  tenderness  of  the  parts,  and  finally  a  discharge  of  either 
pus  or  blood.  In  all  the  cases  so  far  reported  there  have  been  evidences 
of  pulmonary  tuberculosis. 

Treatment. — The  nature  of  the  ulceration  being  undoubtedly  tuber- 
culous, the  treatment  should  be  based  upon  the  same  principles  as  those 
laid  down  for  the  treatment  of  simple  tuberculous  ulceration  of  the' 
anus  and  rectum. 


TUBERCULOSIS    OF   THE    RECTUM    AND    SIGMOID 

Primary  tuberculosis  of  the  lower  portion  of  the  intestinal  tract 
is  exceedingly  rare.  There  are  a  few  instances  in  which  the  disease 
has  been  found  in  the  recta  of  children,  but  in  adults  it  is  almost  un- 
known. As  secondary  to  the  disease  in  other  organs,  however,  it  is 
comparatively  frequent. 

An  examination  of  75  cases  of  tuberculosis  in  all  stages  at  the  Alms- 
house Hospital  showed  ulceration  of  the  rectum  and  sigmoid  in  22 — 
i.  e.,  29.3  per  cent.  This  large  percentage  is  due  to  the  fact  that  many 
of  the  cases  were  selected  for  examination  on  account  of  having  had 
some  intestinal  disturbances.  The  statistics  of  Louis,  Lehbert  and 
Bayle,  Willigk  and  Eisenhart  state  that  lesions  of  the  intestine  occurred 
in  49  to  80  per  cent  of  their  tubercular  patients.  The  ileum  and  csecum 
are  the  most  frequent  sites  owing  to  the  preponderance  of  solitary  folli- 
cles at  these  points.  Fenwick  in  500  autopsies  found  tubercular  ulcera- 
tion of  the  rectum  and  sigmoid  in  14.1  per  cent  and  13.5  per  cent 
respectively.  No  case  is  reported,  however,  in  which  these  were  pres- 
ent without  involvement  of  the  lungs  and  other  organs.  We  have  seen 
two  instances  which  appeared  to  be  primary  tuberculosis  of  the  rec- 
tum. They  were  both  small,  round,  or  elliptical  ulcers  with  ragged, 
undermined  edges,  gray,  conical  bases,  and  not  indurated.  A  few  tu- 
bercle bacilli  were  found  in  the  scrapings,  but  no  giant-cells.  In  one 
case  the  patient  subsequently  developed  pulmonary  tuberculosis,  the 
other  apparently  recovered.  It  is  possible,  of  course,  that  the  bacilli 
may  have  come  down  through  the  intestinal  canal,  lodged  in  the  ulcer, 
and  may  not  have  been  its  cause.  The  facts  and  symptoms,  however,  do 
not  warrant  any  such  conclusion. 

Infection  of  the  intestinal  walls  occurs  through  the  invasion  of  the 
l3'mphoid  or  solitary  follicles  by  tubercle  bacilli.  These  may  enter  the 
canal  through  the  ingestion  of  food,  and  there  is  no  reason  why  they 
may  not  pass  down  and  infect  the  sigmoid  and  rectum.  Abrasion  or 
injury  is  not  necessary  for  the  invasion  by  the  bacillus,  but  no  doubt 
contributes  to  it. 


TUBERCULOSIS  OF  THE  ANUS,   RECTUM,  AND  PELVIC  COLON    207 


Fig.  90. — Tijberculae  Ulceration  of  the  Eectum  with 

Submucous  Fistula. 


Secondary  tuberculosis  of  the  rectum  occasionally  occurs  as  miliary 
deposits  beneath  the  mucous  membrane,  and  frequently  as  ulcerations. 
The  miliary  type  is  generally  secondary  to  tuberculosis  of  the  genito- 
urinary organs,  espe- 
cially of  the  prostate. 
In  two  of  the  cases  ob- 
served, the  condition 
developed  after  the  re- 
moval of  prostates 
which  were  proved  be- 
yond all  doubt  to  be 
tuberculous,  and  in  all 
cases  there  were  symp- 
toms indicating  tuber- 
culosis of  the  genital 
tract.     It  is  always,  so 

far  as  our  experience  shows,  located  in  the  anterior  rectal  wall.  It 
consists  in  little  miliary  deposits  which  feel  like  bird-shot  beneath  the 
mucous  membrane.  These  may  remain  stationary  for  a  long  time,  or 
they  may  break  down  and  form  small  cup-like  ulcers.  The  latter  some- 
times coalesce  and  form  larger  ulcerations,  or  they  may  burrow  and 
connect  with  each  other  underneath  the  mucous  membrane,  thus  form- 
ing small  submucous  fistulas  (Fig.  90). 

In  one  case  it  was  possible  to  scrape  out  one  of  these  little  miliary 
deposits.  It  was  a  round,  cheesy  mass,  quite  firm;  and  under  the 
microscope  it  showed  numerous  round  cells  undergoing  cheesy  degenera- 
tion, with  here  and  there  a  tubercle  bacillus.  No  giant-cells  were  found 
in  this  specimen,  but  their  absence  is  not  unusual  in  such  tubercles. 
The  little  ulcer  from  which  this  tubercle  was  removed  healed  perfectly 
after  cauterization  with  carbolic  acid.     This  condition  has  not  been 

seen  by  the  writer  above  the 
rectum,  and  it  is  not  reported 
in    any    of    the    statistics    to 
which  reference  has  been  made. 
Tubercular  ulceration  of  the 
rectum   and  pelvic   colon   sec- 
ondary to  tuberculosis  of  the 
respiratory   organs   is   not  un- 
common.    It  is  rare  to  find  it 
in  these  portions  without  its  involving  the  ileum,  cgecum,  and  other  por- 
tions of  the  colon,  but  in  2  cases  in  which  the  patients  died  from  pul- 
monary haemorrhage  the  ulcerations  did  not  extend  above  the  sigmoid. 
Histological  examinations  show  that  the  disease  begins  in  the  soli- 


FiG.  91. — Tbaistsvebse  Section  of  Tubercular 
Ulcer  of  the  Eectum,  showing  Elevated 
Center  and  Undermined  Edges. 


208 


THE  ANUS,   RECTUM,   AND   PELVIC   COLON 


Fig.  92. — Tubercular  Ulcer  of  the  Rectum. 


tarv  follicles.  The  lining  cells  of  these  increase,  their  nuclei  multiply, 
giant-cells  are  developed,  the  whole  undergoes  a  caseous  degeneration, 
the  overlying  epithelium  becomes  necrosed,  and  an  ulcer  is  formed.    A 

transverse  section  of  one  of 
these  ulcers  (Fig.  91)  shows  a 
central  elevation,  which  grad- 
ually declines  to  the  periphery 
beneath  the  mucous  membrane, 
thus  causing  an  undermining 
of  the  latter.  In  the  elevated 
portion  of  the  base  small  yel- 
low tubercles  may  sometimes 
be  seen  with  a  low-power  mag- 
nifying-glass,  or  even  with  the 
eye. 

The  ulcers  are  originally 
round  or  elliptical  in  shape, 
but  they  spread  by  degenera- 
tion of  the  borders,  or  coalesce 
with  one  another  until  they 
form  large,  irregular  patches 
(Figs.  92,  93).  The  ulcers  fol- 
low chiefly  the  course  of  the 
blood-vessels  ;  hence,  in  the 
lower  portion  of  the  rectum 
they  spread  in  all  directions,  in 
the  upper  portion  horizontally, 
and  in  the  sigmoid  their  ten- 
dency is  to  encircle  the  canal 
(Fig.  94).  In  this  and  in  the 
colon,  where  the  ulceration  has 
extended  around  the  gut  and 
thus  followed  the  blood-vessels 
and  lymphatics  to  their  end, 
the  process  may  be  arrested, 
the  parts  cicatrize,  and  a  true 
stricture  be  formed.  This 
pathology  may  be  criticized, 
but  the  section  of  a  stricture 
having  tubercular  characteristics  under  the  microscope,  and  with  tuber- 
cular ulcers  above  and  below  it,  is  presented  in  Fig.  95. 

Beneath  all  tubercular  ulcers  there  is  a  deposit  of  fibrous  material, 
whether  they  occur  in  the  intestinal  canal  or  outside  of  it,  which  has 


Fig.  93. — Tubercular  Ulceration  of  the  Rectum. 


Fig.  94. — Tubercular  Ulcer  excirclixg  the 
Sigmoid. 


TUBERCULOSIS  OF  THE  ANUS,  RECTUM,  AXD  PELVIC  COLOX     209 


been  described  as  an  effort  on  the  part  of  Xatiire  to  defend  tissues  against 
the  bacilli  (Fig.  96).  She  builds,  as  it  were,  a  wall  around  the  infec- 
tion, and  so  long  as  it  remains  intact  the  dis- 
ease will  be  limited  to  that  spot.  Green  and 
Martin  have  called  attention  to  this,  saying  it 
explains  why  perforations  so  seldom  take  place 
in  tubercular  ulceration  of  the  intestinal  tract. 

Symptoms. — The  S}anptoms  of  tuberculosis 
of  the  rectum  and  pelvic  colon  will  depend 
upon  the  site  and  extent  of  the  disease.  "WTiere 
it  is  localized  they  will  be  those  of  chronic 
inflammation  of  the  organs — ^viz.,  pain  in  the 
back,  diarrhoea,  or  frequent  desire  to  defecate 
without  relief,  discharges  of  pus,  blood,  and 
mucus,  and  disturbances  of  digestion. 

The  discharges  are  never  so  abundant  as 
in  S}^hilitic  ulceration,  but  the  odor  is  more 
gangrenous.  The  blood  is  never  abundant; 
sometimes  it  is  fresh,  and  at  others  tar-like, 
indicating  that  it  has  been  retained  for  a 
while,  and  ordinarily  it  is  mixed  with  the 
faeces. 

Ashby  says  that  fatal  hgemorrhages  may 
occur  from  these  ulcers,  but  the  statement  is 
not  corroborated  by  other  observers. 

There  is  no  acute  pain  at  the  site  of  the 
ulceration,  and  only  very  rarely  is  there  any 
lessening  of  the  caliber  of  the  gut  to  cause 
obstruction  to  the  facal  passages  in  the  rec- 
tum, but  this  may  occur  in  the  sigmoid. 

To  the  finger  the  ulcers  give  the  impres- 
sion of  a  soft,  granulating  mass  on  a  firm  base, 
and  surrounded  by  irregular,  slightly  thick- 
ened edges.  Through  the  speculum  they  ap- 
pear as  irregular  ulcerations  with  slightly 
elevated,  gray,  sloping  bases,  surrounded  by 
slightly  thickened  and  undermined  edges 
(Fig.  97). 

In  the  last  stages  of  general  tuberculosis, 
where  the  whole  intestinal  tract  from  the 
caecum  down  is  involved,  the  patient  will  suffer 
from  tenesmus,  diarrhoea,  tympanites,  diges- 
tive disturbances,  and  great  emaciation.  The 
14 


Fig.  95.  —  TrsEECuLAR    Stric- 
ture   A^'D    Ulceration    of 

THE    SiGlIOID. 


2l0 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


frequency  of  the  stools  is  distressing,  and  the  discharges  of  pus  and 
black,  tar-like  blood  are  more  abundant. 

Examination  with  the  finger  in  such  cases  docs  not  reveal  much,  as 
the  whole  rectum  is  bathed  in  a  slimy  muco-pus  which  obscures  every- 


FiG.  96. — Photomicrograph  of  Tubercular  Ulcer  of  the  Eectum. 


thing.  After  the  secretion  is  wiped  away,  one  may  see  through  the 
speculum  large  areas  denuded  of  mucous  membrane  with  little  islets  of 
healthy  tissue  here  and  there.  At  other  times  there  appear  linear  ulcer- 
ations branching  like  the  limbs  of  a  tree  from  a  central  point,  and 
forming  little  ulcerated  crevices,  apparently  following  the  lines  of  the 
arterial  supply.  The  mucous  membrane  between  these  tracts  is  swollen, 
red,  and  undermined.  It  soon  breaks  down,  and  the  whole  is  converted 
into  one  large  ulcer,  such  as  has  just  been  described.  This  extreme  con- 
dition is  only  seen  in  late  stages  when  dissolution  is  imminent. 

Diagnosis. — Diagnosis  of  initial  tuberculosis  of  the  rectum  is  very 
difficult.  The  nature  of  the  ulcer,  as  described  above,  its  tendency 
to  follow  the  course  of  the  lymphatics  and  blood-vessels,  the  dead,  gray- 
ish elevated  base  and  undermined  edges,  are  all  indicative  of  the  nature 
of  the  disease.     The  discovery  of  tubercle  bacilli  in  the  discharges  or 

scrapings  from  the  ulcer  would,  of 
course,  settle  its  pathology  to  a  cer- 
tain degree,  but  one  must  always 
bear  in  mind  that  tubercle  bacilli 
may  be  passed  through  the  intes- 
tinal tract,  and  that  they  might  be 
found  in  the  pus  of  an  ulcer,  which 
ulcer  itself  was  not  tubercular.  A 
more  positive  and  certain  diagnosis 
could  be  determined  by  excising  the 
base  and  examining  this  for  giant- 
,cells  and  tubercle  bacilli.  The  cul- 
ture test  is  our  final  resort,  but  this 
is  generally  impractical.  The  clinical  features  of  the  case,  however,  are 
fairly  reliable.  In  those  cases  associated  with  general  or  pulmonary 
tuberculosis  the  history  of  the  case,  the  general  physiognomy  of  the  pa- 
tient, the  character  of  the  ulcers  running  parallel  with  the  blood  and 


Fig.  97. — Tubercular  Ulcer  with  Spud 
introduced  beneath  the  Undermined 
Edge. 


TUBERCULOSIS  OF  THE  ANUS,  RECTUM,  AND  PELVIC  COLON    211 

lymphatic  supply  of  the  rectum^,  the  great  loss  of  fat,  and  the  sunken-in 
condition  of  the  anal  margin,  together  with  the  appearances  of  tuhercle 
bacilli  in  the  discharges  from  the  rectum,  will  serve  to  confirm  a  diag- 
nosis which  is  always  inferred  when  symptoms  of  diarrhoea,  indigestion, 
and  intestinal  disturbances  occur  in  the  tuberculous. 

Treatment. — The  treatment  of  tuberculosis  of  the  rectum  and  pelvic 
colon  is  not  encouraging.  In  a  few  localized  conditions  in  the  rectum 
the  ulcers  may  be  scraped  out,  cauterized,  and  healed  under  the  best 
hygienic  conditions,  but  these  cases  are  very  rare.  In  the  large  majority 
general  tuberculosis  of  the  respiratory  or  genito-urinary  system  will  have 
been  established  before  any  notice  is  taken  of  the  intestinal  complication. 
All  that  can  be  done  in  such  cases  is  to  keep  the  parts  clean  by  colon, 
flushing  with  antiseptic  solutions,  and  protect  them  from  irritation  as 
far  as  possible  by  a  bland  but  nourishing  diet. 

The  hygienic  and  therapeutic  measures  suggested  in  the  section  on 
anal  tuberculosis  are  applicable  here,  but  the  prognosis  is  not  so  favor- 
able. It  is  simply  a  question  of  general  tuberculosis,  the  cure  for  which 
has  not  yet  been  found. 

Hyperplastic  Tuberculosis. — Under  this  title,  suggested  by  Coquet 
(These,  Paris,  1894),  has  been  described  a  peculiar  condition  of  tuber- 
cular infiltration  of  the  intestinal  walls.  It  occurred  most  frequently 
in  the  ileo-C£ecal  region,  but  was  found  in  other  portions  of  the  large 
intestine,  particularly  the  rectum.  Delbet  and  Mouchet  (Archiv.  gen.  de 
med.,  1893,  pp.  513,  668)  referred  to  it  under  the  title  of  rectitis  hyper- 
trophique,  proliferante  et  stenosante.  It  is  characterized  by  extensive 
formation  of  fibrous  and  tuberculous  granulation  tissue  in  the  wall  of 
the  gut.  It  induces  a  sort  of  fibrous  hyperplasia  instead  of  caseation 
and  necrosis.  In  the  large  intestine  it  resembles  scirrhous  cancer  very 
much,  and  even  Billroth  once  removed  a  section  of  the  gut  affected  by 
this  disease  under  the  impression  that  it  was  carcinoma  (Wien.  med. 
Presse,  1891,  p.  193). 

Lartigau  (The  Journal  of  Experimental  Medicine,  vol.  vi,  p.  41)  says: 
"  For  years  hyperplastic  tuberculosis  of  the  rectum  has  been  confused 
with  syphilis  of  this  viscus."  The  pathological  nature  of  this  condition 
in  the  rectum  was  first  pointed  out  by  Sourdille  (Archiv.  gen.  de  med., 
1895,  vol.  i,  pp.  531  and  697;  vol.  ii,  p.  44). 

The  walls  of  the  rectum  are  greatly  thickened,  stiff,  and  indurated. 
They  form  a  cylindrical  tube  which  does  not  collapse  as  does  the  normal 
rectum.  The  mucous  membrane  is  frequently  ulcerated,  but  not  always 
so.  The  chief  seat  of  infiltration  by  round  cells  and  fibrous  tissue,  in 
which  tubercle  bacilli  are  abundant,  is  in  the  submucosa  and  circular  mus- 
cular layers.  Scattered  over  the  mucous  membrane  are  papillomatous 
outgrowths  continuous  with  the  submucosa.     The  solitary  follicles  are 


212  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

swollen  and  inflamed.  Outside  of  the  muscular  layer  of  the  gut  is  a 
fibrous  layer  in  which  the  blood-vessels  present  evidences  of  peri-endar- 
teritis  and  endarteritis.  The  serous  coat  may  be  thickened  or  not; 
in  some  cases  it  is  markedly  so  (Hartmann  and  Pelliet).  The  whole 
presents  a  combination  of  tuberculous  and  simple  inflammatory  lesions. 
Lartigau  claims  that  it  is  purely  local,  if  not  primary,  tuberculosis, 
as  the  lungs  and  other  organs  are  rarely  involved. 

The  diagnosis  of  this  condition  is  exceedingly  difficult.  Its  treat- 
ment is  said  to  be  purely  surgical.  The  writer,  however,  seriously 
doubts  the  propriety  of  operative  interference  in  such  a  chronic,  slowly 
progressive,  tubercular  condition.  In  the  writer's  opinion,  local  inter- 
ference in  such  cases,  just  as  in  chronic  tubercular  fistula,  would  likely 
excite  a  new  activity  in  the  disease  and  do  more  harm  than  good.  In 
all  probability  constitutional  treatment,  fresh  air,  and  good  food,  to- 
gether with  such  local  treatment  as  is  indicated  for  the  prevention  of 
secondary  infection  in  the  ulcers,  would  give  better  results. 

Acute  Tubercular  Inflammation. — Occasionally  there  occurs  an  acute 
inflammation  of  the  rectum  in  which  the  specific  character  is  recognized 
by  the  presence  of  tubercle  bacilli  in  the  discharges  and  in  the  tissues 
themselves.  Earle,  working  under  Councilman,  described  this  in  1887 
as  seen  in  necropsies,  and  later  (Baltimore  Med.  College  Alumni 
Journal,  1899)  as  observed  in  two  clinical  cases.  It  is  characterized  by 
"  swelling  of  the  mucous  membrane,  intense  hyperaemia,  and  numerous 
small  ulcers  " ;  microscopically  the  tissues  showed  small-celled  infiltration 
of  mucous  and  submucous  tissues  verging  upon  caseation  at  points; 
numerous  tubercle  bacilli  were  present  at  these  points,  in  the  margins 
of  the  ulcers,  and  also  in  the  infiltrated  tissues  where  there  was  no 
ulceration. 

In  three  instances  the  process  was  secondary  to  pulmonary  tuberculo- 
sis, and  in  two  it  appeared  to  be  primary.  The  two  clinical  cases 
recovered  under  thorough  drainage,  antiseptic  irrigation,  and  constitu- 
tional treatment  for  tuberculosis. 


CHAPTEE   VII 

VENEREAL  DISEASES  OF  THE  ANUS  AND  RECTUM 

Venereal  diseases  of  the  anus  and  rectum  are  comparatively  rare 
in  the  United  States.  The  enlarged  foreign  population  has  increased 
the  practise  of  sodomy  and  pederasty,  and  every  now  and  then  one 
meets  a  case  of  primary  venereal  disease  in  these  organs.  The  chief 
varieties  are  gonorrhoea,  chancroids,  herpes,  and  syphilis. 

Gonorrhoeal  Proctitis. — This  disease  is  not  so  rare  at  present  as  in 
the  days  of  Bumstead,  Van  Buren,  and  Otis,  who  stated  that  they  had 
never  met  with  a  case.  Its  symptoms  are  so  nearly  like  those  of  simple 
acute  catarrhal  proctitis  that  until  the  discovery  of  the  specific  germ 
by  Neisser  one  could  not  positively  say  whether  a  given  inflammation 
was  of  a  simple  or  specific  nature,  and  its  existence  was  therefore  a 
disputed  point  for  many  years.  In  1874  Bonniere  made  some  interest- 
ing experiments  with  regard  to  the  susceptibility  of  the  mucous  mem- 
branes of  the  body  to  gonorrhoeal  virus;  in  a  patient  with  gonorrhoeal 
ophthalmia  and  urethritis  the  pus  from  the  infected  regions  was 
smeared  upon  the  mucous  membrane  of  the  nose  and  anus.  The  nose 
showed  no  symptoms  of  the  disease,  but  on  the  second  day  evidence 
of  infection  was  seen  about  the  anus,  and  upon  the  fifth  day  purulent 
gonorrhoeal  discharge  from  this  part  was  noticed.  He  then  injected 
the  pus  into  the  rectum  through  a  hollow  tube,  but  with  negative 
results.  From  the  repetition  of  these  experiments  he  concluded  that 
all  the  mucous  membranes  covered  with  pavement  epithelium  or  sup- 
plied with  papillae  and  a  superficial  subepithelial  network  of  lymphatic 
vessels  are  susceptible  to  the  gonorrhoeal  virus ;  while  those  covered  with 
cylindrical  epithelium  and  having  a  superficial  subepithelial  network 
of  veins  are  refractory. 

Typical  blennorrhagia  of  the  anus  is  not  an  uncommon  affection, 
especially  in  women,  and  it  needs  no  argument  or  prolonged  historical 
account  to  prove  its  existence.  In  the  rectum  the  disease  is  compara- 
tively rare,  at  least  it  is  rarely  diagnosed.  Goslin,  Billroth,  Eollet, 
Allingham,  Winslow,  Bernard,  and  Tardieu,  have  all  reported  cases 
of  the  disease,  but  these  writers  based  their  opinions  upon  subjective 

313 


214  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

and  circumstantial  evidence,  the  specific  germ  not  having  been  discov- 
ered at  the  time  of  their  observations.  Xeisser  himself  has  observed 
2  cases  of  rectal  gonorrhcea  in  which  the  microscope  showed  gonococci 
beyond  the  question  of  a  doubt.  Bumm  quotes  a  case  observed  by 
Wolff  with  a  distinct  history  of  the  practise  of  sodomy  in  which  the 
discharge  contained  numeroiis  well-defined  gonococci. 

Matterstock  reported  a  case  from  the  i^ractice  of  Frisch  in  great  de- 
tail; he  not  only  examined  the  discharge  during  life,  but  also  sections 
of  the  mucous  membrane  taken  post  mortem.  The  patient  was  a  girl 
seventeen  years  of  age,  a  sodomist  by  practice,  who  suffered  from  pain 
and  burning  in  the  rectum  which  was  unbearable  at  defecation.  These 
symptoms  came  on  about  fifteen  days  after  her  last  coitus  per  rectum. 
The  anus  was  funnel-shaped,  reddened,  and  showed  some  loss  of  epithe- 
lium. There  was  a  perianal  eczema,  and  the  pus  oozed  out  between  the 
swollen  radial  folds.  This  pus  contained  numerous  gonococci,  some 
free  and  others  enclosed  in  the  pus-cells.  _  There  were  both  cylindrical 
and  squamous  epithelial  cells  floating  about  in  the  pus,  and  now  and 
then  a  pus-cell  appeared  which  was  literally  stuifed  full  of  gonococci 
so  as  to  give  the  nucleus  a  crescentic  shape. 

The  woman  also  had  a  discharge  from  the  genitals,  in  which  a 
similar  exhibition  of  gonococci  was  found.  Through  the  speculum  the 
mucous  membrane  of  the  rectum  appeared  swollen,  bright-red,  and 
bathed  in  pus.  At  a  distance  of  about  4  centimeters  (If  inches)  from 
the  anal  margin  there  was  a  shallow  erosion  or  ulceration  of  the  mucous 
membrane.  This  patient  died  from  pulmonary  disease  before  the  gon- 
orrhceal  affection  was  cured,  notwithstanding  the  treatment  had  been 
kept  up  for  about  six  months.  The  mucous  membrane  of  the  rectum 
was  excised  post  mortem  and  the  histological  examination  showed  a 
partial  disappearance  of  the  Lieberkiihn  follicles,  together  with  exfolia- 
tion of  cylindrical  epithelium ;  there  was  a  typical  proliferation  of  cells 
and  connective-tissue  infiltration  of  the  borders  of  the  ulcers  and  con- 
siderable infiltration  of  the  muscular  walls  of  the  rectum  by  round  cells 
containing  single  nuclei.  In  the  pol^Tiucleated  round  cells  were 
abundant  gonococci,  which  were  also  free  in  the  superficial  layers  of 
the  mucosa.  "  Their  presence  was  limited  to  the  parts  covered  with 
cylindrical  epithelium,  while  the  infiltration  of  the  round  cells  de- 
scended to  the  margin  of  the  external  sphincter"  (Annales  de  dermat., 
Paris,  1893,  p.  330).  These  facts  are  practically  confirmed  by  Hart- 
mann  and  Quenu,  who  state  that  the  limitation  of  the  gonococci  to 
the  superficial  layers  of  the  mucous  membrane  is  accompanied  by  dif- 
fuse inflarmnatory  infiltration  of  the  deeper  tissues  where  the  cocci 
are  absent. 

In  1893  the  author  reported  (Jour.  Cutan.  Venereal  Diseases)  3  cases 


VENEREAL  DISEASES  OF   THE  ANUS  AND  RECTUM  215 

of  gonoeocci  of  the  rectum,  in  which  the  discharges,  taken  from  2-| 
inches  above  the  anal  margin,  showed  free  gonoeocci,  and  pus  and 
epithelial  cells  crowded  full  of  them.  Since  that  time  3  other  cases 
have  been  observed,  in  2  of  which  there  was  also  blennorrhagia  of  the 
anus  at  the  same  time.  In  these  6  cases  in  which  the  rectum  has  been 
affected,  the  condition  has  not  been  as  obstinate  as  that  reported  by  Mat- 
terstock,  although  the  pathological  examinations  have  exhibited  prac- 
tically the  same  changes.  It  is  a  question  whether  his  case  did  not 
have  tuberculosis  of  the  rectum  complicating  the  gonorrhoea.  As  a 
matter  of  fact  urethral  gonorrhoea  is  always  very  slow  in  healing  in 
tubercular  patients,  and  the  same  may  be  the  case  in  that  of  the 
rectum.  While,  therefore,  one  may  say  that  the  rectal  mucous  mem- 
brane is  less  susceptible  to  the  gonorrhceal  poison  than  is  that  of  the 
urethra  and  anus,  nevertheless  it  may  be  attacked.  Especiall}^  is  this 
the  case  when  there  is  constipation  or  any  other  cause  which  produces 
slight  traumatisms  of  the  mucous  membrane  during  the  presence  of  the 
gonoeocci  in  the  rectum. 

Etiology. — The  cause  of  this  disease  is  undoubtedly  the  direct 
inoculation  of  the  mucous  membrane  of  the  rectum  or  anus  by  the 
gonorrhceal  virus.  This  occurs  through  extension  of  the  disease  from 
the  vulva  to  the  anus  and  rectum,  through  careless  handling  of  other 
parts  affected  with  the  disease,  and  consequent  conveyance  of  specific 
germs  to  the  rectum,  or  by  unnatural  coitus,  the  active  party  being 
affected  with  the  disease.  It  has  been  claimed  that  it  may  occur 
through  metastasis,  but  such  an  origin  is  unlikely. 

Eollet  (Diet,  encyc.  des  sciences  med.)  has  reported  a  case  in  which 
infection  occurred  in  a  patient  who  suffered  from  an  urethral  discharge 
and  introduced  his  finger  into  the  rectum  in  order  to  produce  a  move- 
ment of  the  bowels.  The  finger  was  evidently  infected  with  the  dis- 
charge and  thus  inoculated  the  mucous  membrane  of  the  rectum.  In 
Matterstock's  case,  and  in  3  of  the  author's,  the  condition  was  brought 
about  by  the  practise  of  unnatural  vice,  and  this  is  perhaps  the  most 
frequent  source  in  men.  In  women,  however,  gonorrhoea  of  the  anus 
is  usually  due  to  secondary  inoculation  from  vaginal  discharges. 

Symptoms. — The  symptoms  of  the  disease  are  sensations  of  uneasi- 
ness, itching,  and  heat  about  the  anus,  which  may  occur  at  any  time 
from  twenty-four  hours  to  five  days  after  exposure.  These  rapidly 
grow  more  distinct,  the  heat  changes  into  a  burning,  the  itching  into 
pain,  defecation  beconies  onerous,  and  the  patient  suffers  constantly 
from  dull,  heavy  aching  in  the  sacral  region.  From  the  fifth  to  the 
seventh  day  the  patient  will  probably  have  constitutional  disturbances, 
the  pulse  and  temperature  becoming  elevated.  There  is  frequent  desire 
to  go  to  stool,  followed  by  the  passage  of  mucus  and  pus,  and  when 


216  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

the  fecal  passages  occur  they  are  tinged  with  blood  and  accom- 
panied by  great  pain.  The  discharge  is  at  first  thin  and  milky-white, 
but  later  greenish  or  brownish-yellow  and  very  abundant  in  quantity. 
The  appearance  of  the  anus  and  rectum  will  depend  upon  the  habits 
of  the  patient  and  the  parts  involved.  If  he  be  a  sodomist  the  anus 
will  appear  infundibuliform,  the  sphincters  will  be  relaxed,  and  there 
will  be  a  pouting  or  exstrophy  of  bright-red  oedematous  mucous  mem- 
brane about  the  orifice;  the  muco-cutaneous  folds  will  be  bathed  in  pus, 
excoriated  or  ulcerated,  and  fissures  formed.  Haemorrhoids  are  not 
generally  developed  by  this  infiammatory  process,  and  will  not  be  pres- 
ent unless  they  existed  before  the  infection. 

When  the  disease  involves  the  rectum  the  mucous  membrane  be- 
comes bright  red,  swollen,  tense,  and  painful.  It  bleeds  upon  touch, 
is  bathed  in  a  profuse  secretion  of  muco-pus  which  dribbles  from  the 
anus,  this  orifice  being  imperfectly  closed  on  account  of  the  swollen 
folds.  As  the  disease  progresses  patches  of  excoriation  or  ulceration 
occur.  This  ulceration  is  superficial,  the  edges  are  never  undermined, 
and  the  base  is  granulating. 

Condylomata,  fissure,  and  submucous  fistula  may  complicate  the 
condition.  The  disease  in  the  anus  is  self-limited,  and  if  proper  atten- 
tion to  hygiene  and  cleanliness  is  observed  the  patients  will  rapidly 
recover  in  the  majority  of  cases.  Probably  a  very  small  proportion  of 
these  cases  are  ever  seen  by  physicians;  the  invalids  being  ashamed  of 
their  practices,  suffer  from  their  ailments  and  treat  themselves  rather 
than  be  exposed  and  degraded  by  the  examinations  and  admissions 
which  medical  treatment  would  entail.  If  the  disease  extends  above 
the  internal  sphincter  it  may  persist  for  long  periods  and  become 
chronic.  While  no  case  of  stricture  from  this  cause  has  been  reported, 
it  is  not  unreasonable  to  suppose  that  the  same  inflammatory  deposit 
and  cicatricial  contraction  which  follows  this  disease  in  the  urethra 
may  also  be  developed  in  the  walls  of  the  rectum. 

Diagnosis. — The  diagnosis  depends  largely  upon  the  presence  of 
gonococci  in  the  discharges.  The  profuse  and  purulent  nature  of  the 
latter,  the  extreme  irritation,  and  the  coexistence  of  gonorrhoeal  in- 
flammation in  other  organs,  are  all  indicative  of  the  nature  of  the 
disease.  The  final  test,  however,  is  the  finding  of  Neisser's  coccus. 
The  specimens  for  examination  must  be  collected  in  a  most  careful 
manner  in  order  to  eliminate  any  possibility  that  the  pus  comes  from 
the  genital  organs;  the  anus  is  wiped  off  as  gently  and  thoroughly  as 
possible  with  absorbent  cotton,  then  washed  with  an  antiseptic  solution 
of  boric  acid  or  bichloride  of  mercury,  and  then  a  speculum,  such  as 
the  Kelly  anoscope  or  the  author's  conical  instrument,  is  introduced 
with  the  patient  lying  upon  the  left  side  or  in  the  knee-chest  posture. 


VENEREAL  DISEASES  OF  THE  ANUS  AND  RECTUM  217 

The  specimen  should  be  taken  with  a  platinum-wire  loop  from  the  wall 
of  the  rectum  and  not  from  the  discharge  which  flows  down  into  the 
speculum,  lest  by  any  chance  some  of  the  secretion  from  the  anus  should 
have  been  carried  upward  on  the  end  of  the  instrument.  Several  speci- 
.  mens  should  he  examined  to  corroborate  one  another.  The  methods 
of  staining  and  the  typical  appearance  of  these  gonococci  are  well 
described  in  books  upon  bacteriology  and  genito-urinary  diseases,  and 
need  not  be  detailed  here.  Blake  and  Shuldham  tell  us  that  "  when 
gonorrhoea  has  reached  the  chronic  stage  we  may  fail  to  find  the  dip- 
lococci  or  true  gonococci,  but  encounter  instead  pseudo-gonococci, 
staphylococci,  streptococci,  or  tubercle  bacilli."  Therefore  the  nega- 
tive diagnosis  should  not  depend  alone  upon  not  finding  these  bacilli. 
The  history  of  the  case,  the  appearance  of  the  anus,  the  relaxed 
sphincters,  the  excessive  discharge,  the  extreme  pain  on  defecation,  and 
the  fissures  between  the  anal  folds  should  all  be  considered  in  coming 
to  a  final  conclusion. 

Prognosis. — The  prognosis  in  these  cases  is  favorable  when  the  indi- 
viduals are  otherwise  healthy.  If,  however,  there  be  a  tubercular  di- 
athesis or  constitutional  syphilis,  manifestations  of  these  diseases  are 
likely  to  develop  during  an  attack  of  rectal  gonorrhoea,  either  of  which 
renders  the  prognosis  very  serious  and  the  course  of  the  disease  exceed- 
ingly protracted.  This  was  the  condition  in  the  case  reported  by  Mat- 
terstock,  in  which  the  disease  lasted  for  over  six  months,  showing  little 
tendency  to  heal.  The  patient  died  at  the  end  of  this  period  from 
general  tuberculosis.  Why  it  should  be  so  it  is  difficult  to  answer, 
but  the  fact  remains  that  acute  inflammations  of  the  rectum,  from 
whatever  cause,  are  very  liable  to  become  chronic  and  intractable,  even 
incurable,  in  cases  affected  with  pulmonary  tuberculosis.  Therefore  in 
cases  with  such  diatheses  our  prognosis  should  be  very  guarded. 

Treatment. — In  anal  gonorrhoea  the  parts  should  be  kept  clean  by 
frequent  sponging  with  antiseptic  solutions,  such  as  bichloride  of  mer- 
cury, Thiersch's  solution,  or  solutions  of  creolin.  Nitrate  of  silver 
in  mild  percentages,  argonin,  argyrol,  and  permanganate  of  potash 
rapidly  destroy  the  gonococci,  and  are  therefore  very  useful;  when  the 
disease  has  progressed  to  excoriation,  or  when  ulceration  has  occurred, 
these  local  applications  should  be  repeated  two  or  three  times  a  day, 
and  the  parts  should  be  protected  from  rubbing  against  each  other  by 
small  pledgets  of  gauze  or  cotton  soaked  in  antiseptics.  As  soon  as 
the  gonococci  disappear  from  the  discharges,  it  is  well,  after  cleansing 
the  parts  thoroughly,  to  apply  some  inert  powder,  such  as  stearate  of 
zinc,  oxide  of  zinc  and  calomel,  subiodide  of  bismuth  or  aristol,  insuf- 
flating it  well  between  the  mucous  folds  frequently  enough  to  keep  the 
parts  dry.     If  there  are  condylomata  they  may  be  clipped  off,  or  better, 


218  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

still  cauterized  with  inonochloracetic  acid,  and  kept  dry  with  the  powder 
as  before. 

Where  the  ulceration  is  deep  or  sluggish,  cauterization  with  nitrate 
of  silver  should  be  used. 

The  bowels  should  be  kept  open,  but  it  is  not  well  to  induce  fre- 
quent diarrhoeal  passages  because  they  irritate  even  more  than  a  solid, 
well-formed  movement.  If  there  be  concomitant  disease  of  the  genital 
organs,  the  vagina  should  be  tamponed  regularly  in  order  to  avoid  the 
dribbling  down  of  the  fresh  discharges  from  these  organs  upon  the  anal 
surfaces.  Ordinarily  there  will  be  no  necessity  to  dilate  the  sphincter 
in  such  cases,  and  yet  there  may  arise  emergencies  from  pain  and  spasm 
of  this  muscle  which  would  necessitate  this  procedure,  which  should 
be  performed  only  as  a  last  resort,  as  it  would  likely  deepen  the  fissure- 
like ulcerations,  increase  the  inflammation,  and  probably  result  in  the 
infection  of  the  rectum,  whereas  the  disease  was  originally  limited  to 
the  anus.  When  the  disease  has  involved  the  rectum,  active  and  ener- 
getic measures  are  requisite;  irrigation  with  boric  acid  or  very  mild 
solutions  of  bichloride  of  mercury  (1  to  10,000),  or  permanganate  of 
potash  (1  to  4,000)  should  be  made  two  or  three  times  a  day.  It  is 
scarcely  necessary  to  remark  here  that  rectal  enemata  do  not  answer 
the  purposes  of  irrigation  in  these  cases.  Permanganate  of  potash  of 
a  strength  sufficient  to  be  bactericidal  is  very  irritating  to  the  intestinal 
canal  if  left  there  for  any  time,  and  brings  on  intense  and  painful 
griping.  Therefore  it  is  important  that  a  proper  rectal  irrigator  should 
be  used,  such  as  that  illustrated  in  Fig.  83;  or  if  the  anus  be  too  tender 
for  the  introduction  of  instruments  like  this,  two  soft-rubber  catheters 
should  be  introduced  and  the  irrigation  carried  on  by  using  one  of 
these  as  an  inflow  and  the  other  as  an  exit  for  the  solution. 

If  there  is  much  spasm  of  the  sphincter  and  pain  from  defecation, 
dilatation  of  the  muscles  should  be  carried  out  under  anassthesia.  In 
such  conditions  this  operation  may  be  resorted  to  earlier  than  in  the 
cases  in  which  the  anus  only  is  affected,  as  there  will  be  no  longer  any 
fear  of  infecting  the  rectum,  and  the  operation  will  furnish  proper 
drainage  and  relief  for  the  accumulated  discharges. 

Jullien  advises  the  use  of  tannic  acid  as  an  application  to  the  anus, 
but  it  is  too  irritating  and  not  as  satisfactory  as  the  powders  mentioned 
above.  The  application  of  pure  ichthyol  to  the  fissures  will  hasten  the 
healing.  If  a  submucous  fistula  should  occur,  it  must  be  laid  open 
at  once  and  treated  as  an  ulcer  so  that  it  can  not  act  as  a  hiding-place 
for  the  gonococci  from  which  they  may  break  forth  and  reinfect 
the  parts. 

The  irrigations  should  not  be  discontinued  until  eight  or  ten  days 
after  the  discharge  has  entirely  ceased,  for  the  gonococci  are  liable  to 


VENEREAL  DISEASES   OF   THE  ANUS  AND   RECTUM  219 

be  concealed  in  the  follicles  and  the  discharge  may  be  lighted  up  again 
several  days  after  it  has  once  ceased. 

Eest  in  bed  is  essential  to  successful  treatment,  especially  when  the 
rectum  is  involved;  but  this,  like  every  other  rule,  must  have  a  certain 
amount  of  elasticity.  Cases  inclined  to  ansemia,  debility,  and  tubercu- 
losis do  not  stand  confinement  in  bed  very  well,  and  it  is  wise  to  alter- 
nate it  with  periods  of  mild  exercise  in  fresh  country  air.  Bitter  tonics, 
cod-liver  oil,  predigested  foods,  and  occasionally  a  little  wine  will  be 
found  of  advantage  in  bringing  up  the  strength  of  these  patients,  and 
sometimes  accomplish  a  cure,  whereas  the  simple  local  treatment  has 
resulted  in  failure. 

Chancroid  of  the  Anus. — This  is  a  not  infrequent  disease  about  the 
anus,  and  in  this  position  the  characteristics  vary,  as  may  be  accounted 
for  by  the  anatomical  relations  of  the  parts,  their  functional  activity, 
and  the  hygienic  care  which  is  devoted  to  them  by  the  lower  classes,  in 
which  the  affection  is  generally  found. 

In  the  United  States  it  is  comparatively  rare,  but  in  Europe  and 
the  Eastern  continent  it  is  not  at  all  infrequent;  nearly  all  of  those 
observed  in  the  author's  clinic  have  been  negroes  or  emigrants  from 
southern  Europe.  Fournier  states  that  he  found  the  disease  in  1  in 
445  men  and  in  1  in  9  women  suffering  from  venereal  diseases.  Periodi 
found  2  out  of  83  cases  of  venereal  disease,  both  in  women.  Sturgis 
found  8  in  the  same  number  of  cases,  all  in  women.  Jullien  is  said  to 
have  found  14  cases  of  this  condition  in  a  total  of  42  chancroidal  ulcers 
(Quenu  and  Hartmann,  Chir.  d.  rectum,  vol.  i,  p.  404).  Sick,  in  his  re- 
view of  venereal  diseases  in  the  Hamburg  General  Hospital  from  1880  to 
1890,  found  only  1  case  of  chancroid  in  the  anus  in  9,884  men,  whereas  in 
11,826  women  and  infants  he  found  224  affected  with  it.  From  these  fig- 
ures one  can  readily  observe  that  while  in  men  chancroid  of  the  anus  is  a 
very  rare  affection,  it  is  by  no  means  uncommon  in  women.  This  fre- 
quency in  the  female  sex  results  from  the  close  proximity  of  the  anus 
to  the  genital  organs  and  the  facility  with  which  discharges  from  the 
vagina  may  trickle  down  upon  the  anal  region.  It  is  due  occasionally 
to  contact  with  the  male  organ  during  the  act  of  coition,  and  also 
to  the  comparatively  greater  frequency  of  the  practise  of  sodomy  than 
of  pederasty.  In  the  majority  of  cases  chancroids  of  the  anus  are 
secondary  to  chancroids  elsewhere,  and  therefore  may  be  said  to  be 
due  to  auto-inoculation.  They  are  usually  limited  to  the  perianal 
region  and  the  anal  canal,  and  rarely  extend  above  the  muco-cutaneous 
border  unless  they  assume  the  phagedenic  type,  when  they  may  involve 
the  rectal  mucous  membrane  and  result  in  great  destruction  of  tissue, 
even  of  the  muscular  wall  of  the  gut. 

Etiology. — There  are  two  theories  in  regard  to  the  origin  of  chan- 


220  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

croids,  in  both  of  which  it  is  assumed  that  the  disease  is  the  result  of 
the  local  action  of  micro-organisms.  The  later  schools  have  generally 
accepted  the  theory  that  a  chancroid  is  nothing  more  than  an  ulcera- 
tion due  to  the  inoculation  of  abraded  surfaces  by  pyogenic  microbes. 
They  account  for  the  special  characteristics  of  the  ulceration  by  re- 
ferring them  to  the  anatomical  and  physiological  characters  of  the  parts 
in  which  they  occur;  they  hold  that  inoculation  in  this  region  with 
pus  from  other  suppurating  conditions,  such  as  pustules,  carbuncles, 
or  furuncles,  will  produce  characteristic  chancroids,  and  finally,  that 
these  sores  occur  in  people  who,  owing  to  their  bad  hygienic  habits, 
are  susceptible  to  infection  by  micro-organisms.  On  the  other  hand, 
good  authorities  claim  that  the  chancroid  is  due  to  inoculation  with  a 
specific  virus ;  they  claim  to  have  found  certain  bacteria  always  asso- 
ciated with  the  pyogenic  micro-organism  in  chancroidal  lesions  which 
are  capable  in  pure  cultures  of  reproducing  the  ulcers  even  when  the 
inoculations  are  practised  under  aseptic  precautions.  In  support  of 
these  theories  they  hold  that  a  chancroid  always  results  from  contact 
with  the  discharge  from  a  chancroid,  and  does  not  result  from  inocula- 
tion by  discharges  from  other  sources ;  that  the  chancroid  always  runs 
a  typical  course  in  a  given  location;  that  auto-inoculation  can  be  suc- 
cessfully repeated  almost  indefinitely,  and  that  the  inoculated  ulcers, 
after  two  or  three  generations,  cease  to  contain  pyogenic  microbes. 

Ducrey,  Welander,  and  Krefting  "  describe  as  the  specific  micro- 
organism of  chancroid  a  short,  thick  bacillus  with  rounded  ends  much 
like  a  dumb-bell,  about  ^  a  micromillimeter  in  length.  The  micro- 
organism is  found  in  the  protoplasm  and  between  the  cells,  often  in 
chains  and  groups  "  (White  and  Martin,  Venereal  Diseases,  p.  274). 
They  describe  the  characteristics  of  this  ulceration,  and  state  further 
that  in  no  instance  was  auto-inoculation  successful  from  a  chancroid 
in  which  this  bacillus  was  not  present.  Many  other  observers  have 
failed  to  confirm  these  observations,  and  inasmuch  as  proof  afforded 
by  the  inoculation  of  pure  culture  is  still  wanting,  one  must  conclude 
that  the  presence  of  a  specific  virus  is  stih  judice. 

Perianal  Chancroids. — Chancroids  occurring  in  the  cutaneous  tis- 
sue around  the  anus  upon  the  perineal  and  coccygeal  regions  possess 
the  characteristics  of  erosions  more  than  ulcerations.  They  are  shallow, 
do  not  discharge  a  great  amount  of  pus,  and  show  little  tendency  to 
spread.  So  frequently  are  they  associated  with  the  condition  else- 
where that  one  writer  has  termed  them  "  satellites  of  other  chan- 
croids." They  are  more  often  multiple  than  single,  as  many  as  fifteen 
being  seen  in  one  case  (Fig.  98).  vSome  doubt  the  chancroidal  nature 
of  such  ulcers  and  claim  that  they  are  only  inflammatory  phenomena, 
but  the  facts  remain  that  they  are  secondary  to  chancroids  elsewhere; 


VENEREAL  DISEASES   OF   THE  ANUS  AND  RECTUM 


221 


they  are  auto-inoculable;  they  are  associated  with  hypertrophy  and  sup- 
puration of  the  lymphatics,  and  do  not  tend  to  burrow  underneath  the 
skin.  These  characteristics  seem  to  distinguish  them  from  general 
ulcerative  conditions. 

A7ial  Chancroids. — The  sulci  between  the  radiating  folds  of  the 
anus  form  a  most  excellent  lodging-place  for  chancroidal  germs,  and 
owing  to  the  frequent  breaks  in  the  mucous  membrane  at  these  points 
inoculation  occurs  with  the  greatest  facility.  Here  the  chancroids 
appear  as  grayish-yellow  fissures  between  the  folds,  and  might  be  over- 
looked in  the  beginning  except  for  the  pain  which  they  produce.     They 


Fia.  98. — Multiple  Perianal  Chaj^croids. 


may  be  distinguished  from  simple  fissures  by  the  existence  of  chan- 
croids elsewhere  in  the  body;  by  their  color,  which  is  less  bright  and 
red;  by  the  secretion  of  pus,  which  is  much  more  abundant;  by  their 
being  multiple,  and  finally  by  the  fact  that  they  are  auto-inoculable. 

So  far  as  the  pain  is  concerned  there  is  no  difference  between  these 
ulcers  and  the  true  irritable  ulcer  of  Allingham.  As  a  rule  they  involve 
the  cutaneous  and  subcutaneous  tissues  freely,  but  seem  to  be  arrested 
at  the  level  of  the  mucous  membrane.  They  may  extend  through  one 
of  the  sulci  between  the  radial  folds  until  they  reach  the  upper  end 
of  the  anal  canal.  Here  and  below  the  folds  they  spread  circularly 
around  the  anus  and  thus  take  on  a  sort  of  hour-glass  shape.     In  this 


222  THE  ANUS,  RECTtM,  AND  PELVIC  COLON 

position  extreme  chronicity  is  their  chief  characteristic.  They  advance 
slowly  and  heal  equally  so.  The  chancroid  in  one  sulcus  infects  an- 
other and  another  until  the  whole  anal  circumference  may  be  involved. 
The  base  is  gray  and  sluggish,  the  secretion  is  free,  sometimes  fetid  and 
tinged  with  blood,  and  occasionally  little  fistulas  pass  through  the  folds 
from  one  sulcus  to  another.  Molliere  has  stated  that  if  the  case  be  com- 
plicated with  hsemorrhoids  the  virulence  may  die  out,  leaving  simple 
varicose  ulcers  which  are  not  auto-inoculable  (Maladies  du  rectum, 
p.  679). 

Extreme  pain  following  defecation  brings  on  constipation  in  these 
cases  just  as  it  does  in  simple  fissure.  The  patients  in  consequence 
suffer  all  the  symptoms  of  irregular  faecal  movements,  loss  of  sleep, 
and  reflex  digestive  derangements. 

Treatment. — There  is  little  tendency  toward  spontaneous  healing, 
and  frequently  it  is  impossible  to  bring  this  about  without  forcible 
divulsion  of  the  sphincter. 

It  should  always  be  remembered  before  having  recourse  to  the 
knife  or  forcible  stretching  of  the  sphincters,  that  these  practices  open 
up  the  lymphatic  channels  for  the  absorption  of  pus  and  may  result, 
as  in  the  case  of  Kicord  and  Foumier,  in  septicaemia,  phagedaena,  and 
death.  One  should  therefore  be  slow  in  recommending  such  a  radical 
measure.  The  excessive  pain  and  the  entreaties  of  the  patient  for 
relief,  incline  one  to  operate  at  once;  but  in  one  ease  in  which  the 
sphincter  was  divulsed,  the  ragged  edges  of  the  hypertrophied  radiating 
folds  cut  off  and  a  dirty,  irregular,  ulcerating  mass  surrounding  the 
anus  cleaned,  the  pain  was  relieved  for  twenty-four  hours,  then  re- 
turned in  all  its  severity  and  was  followed  in  a  few  days  by  perianal 
abscess  and  a  suppurating  inguinal  bubo.  Either  of  these  conditions 
might  have  occurred  without  the  operation,  but  they  were  not  present 
before  or  at  the  time  of  the  operation,  and  it  is  possible  that  the  pro- 
cedure was  the  cause  of  them. 

Conservative  treatment  therefore  ought  always  to  be  practised,  and 
practised  patiently  before  undertaking  any  operation.  The  bowels 
should  be  kept  open  by  mild  laxatives,  not  by  cathartics,  and  the  parts 
cleansed  by  frequent  bathing  with  antiseptic  solutions  and  .the  applica- 
tion of  soft,  soothing  dressings.  The  following  treatment  advised  by 
the  author  in  Morrow's  System  of  Genito-Urinary  Diseases  has  proved 
satisfactory  in  most  of  his  cases : 

The  parts  after  being  thoroughly  washed  and  cleansed  are  touched 
with  a  solution  that  contains  equal  parts  of  carbolic  acid  and  tincture 
of  iodine.  This  is  followed  by  washing  with  lime-water  or  blackwash 
and  applying  a  powder  of  calomel  and  oxide  of  zinc.  If  the  ulcer  ex- 
tends within  the  anus  it  may  be  necessary  to  introduce  a  speculum  in 


VENEREAL   DISEASES   OF  THE  ANCS   AND   RECTmi  223 

order  to  treat  the  j^arts  thoroughly.  One  should  do  this  even  if  the 
pain  is  severe  enough  to  necessitate  the  administration  of  nitrous  oxide 
or  ethyl  chloride  for  every  treatment.  Methylene  blue,  10  grains  in 
each  fluid  ounce,  is  an  excellent  application  in  these  cases,  especially 
where  there  is  a  tendency  to  chronicity  or  phagedena. 

The  insufflation  of  orthoform  upon  these  ulcers  will  in  many  in- 
stances relieve  the  acute  pain  produced  by  dressing  them;  it  is  not 
■uniform  ia  its  action,  however,  for  in  some  cases  it  has  not  given  the 
slightest  relief.  Iodoform  is  said  to  possess  a  speciflc  action  upon  chan- 
croidal ulcers;  in  hospital  practice  one  may  use  it  freely,  but  its  disa- 
greeable odor  has  ostracized  it  so  far  as  private  patients  are  concerned. 
Aristol,  antinosin,  and  resiaol  may  all  be  used  in  place  of  the  above 
powder,  as  may  the  mixture  of  oxide  of  zinc  and  calomel,  which  is 
simpler  and  much  less  expensive. 

Chancroidal  Ulceration  of  the  Rectum. — Some  few  cases  have  been 
described  in  which  the  chancroidal  ulceration  has  extended  from  the 
anus  into  the  rectum,  but  these  can  not  be  considered  true  rectal  chan- 
croids. A  chancroid  of  the  rectum  itself  must  originate  in  that  organ 
and  is  usually  due  to  sodomy. 

Chancroidal  ulcers  occurring  around  the  margin  of  the  anus  do  not 
pass  easily  beyond  this  region,  from  the  fact  that  the  sphincter  con- 
stantly closes  this  aperture  and  acts  as  a  barrier  to  advancing  germs. 
The  fffical  movements  also  sweep  out  before  them  the  germs  that  may 
have  nearly  gained  access  to  the  rectal  cavity.  Those  chancroids  of 
the  rectum  which  have  been  reported  have  generally  been  associated 
with  others  about  the  anus  and  upon  the  buttocks,  and  it  is  much  more 
logical  to  attribute  the  latter  ulcers  to  infection  from  within  the  rectum 
than  vice  versa. 

That  chancroids  may  extend  from  the  anus  into  the  rectum  must 
be  admitted.  All  who  have  had  much  experience  in  rectal  and  venereal 
diseases  have  seen  such  cases.  The  fact  that  the  invalids  affected  do 
not  even  give  up  their  vicious  practices  while  the  sore  exists  renders 
it  possible  that  the  virus  may  be  carried  upward  into  the  rectum,  and 
the  ulcers  are  thus  the  result  of  auto-inoculation.  On  the  other  hand, 
a  certain  variety  of  chancroid  known  as  phagedenic  has  a  persistent 
tendency  to  progi-ess  in  one  or  more  directions,  and  if  the  sphincter 
muscle  is  relaxed,  as  it  frequently  is  in  this  class  of  patients,  there 
will  be  no  obstructive  barrier  against  the  progress  of  the  disease  into 
the  rectum.  Mason,  Van  Buren,  and  others  have  reported  such  cases  as 
this,  and  claim  that  they  have  seen  strictures  of  the  rectum  caused 
by  them. 

Symptoms. — The  s}'mptoms  of  chancroids  of  the  rectum  are  iri  the 
main  those  of  ulceration,  viz. :  diarrhoea,  tenesmus,  and  a  profuse  dis- 


224  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

charge  of  pus,  sometimes  tinged  with  blood.  Tliere  may  or  jiiay  not 
be  pain.  The  patient  is  generally  unwilling  to  confess  that  he  has  any 
knowledge  of  the  cause  of  his  disease. 

The  ulcers  are  irregular  in  shape,  grayish  in  color,  and  shallow 
with  ragged  borders  and  pale,  feeble  granulations.  They  may  be  sta- 
tionary or  have  a  tendency  to  rapidly  extend.  Occasionally  they  involve 
the  deeper  tissues  of  the  gut,  invade  the  submucous  and  muscular 
coats,  and  may  even  destroy  the  sphincter  itself.  Under  such  circum- 
stances they  are  termed  phagedenic.  When  a  tendency  to  spread  exists 
the  pus  burrows  underneath  the  mucous  membrane,  and  submucous 
or  submuscular  fistulas  may  develop. 

TreaUnent. — The  management  of  chancroids  within  the  rectum  is 
practically  the  same  as  that  of  acute  ulceration  of  this  organ.  The 
patient  should  be  confined  to  bed.  The  bowels  should  be  kept  regular 
but  not  diarrhoeal,  and  the  rectum  should  be  irrigated  with  antiseptic 
solutions,  such  as  boric  acid,  thymol,  bichloride  of  mercury,  carbolic 
acid,  etc.,  two  or  three  times  a  day.  If  the  ulcer  appears  sluggish, 
slightly  stimulating  applications  will  sometimes  be  useful.  If  it  has 
a  tendency  to  progress  rapidly,  the  application  of  pure  nitric  acid  or 
the  actual  cautery  to  its  edges  will  sometimes  check  this.  Iodoform 
suppositories  are  very  useful  in  these  conditions ;  though  pure  carbolic 
acid  applied  once  in  three  or  four  days,  and  the  daily  insufflation  of 
the  zinc  and  calomel  powder  upon  the  ulcer  produces  excellent  results. 
Pure  ichthyol  acts  well  in  fissures  when  they  exist.  A  bland,  unstim- 
ulating  diet  should  be  enforced,  and  morphine  should  be  administered 
if  necessary  to  relieve  the  pain  and  control  too  frequent  stools. 

Phagedenic  Chancroid. — Any  chancroid  may  assume  a  phagedenic 
condition,  which  may  be  either  acute  or  chronic.  This  change  in  the 
nature  of  the  ulcers  is  due  to  constitutional  conditions.  Diday  and 
Doyon  (Therapeutique  des  malad.  vener.  et  des  malad.  cutan.,  1876,  p. 
184)  have  proved  this  fact  by  experiments  with  inoculation.  They 
have  shown  that  if  a  healthy  person  is  inoculated  from  a  phagedenic 
chancroid  he  develops  only  a  simple,  soft  sore;  and  on  the  other  hand, 
if  a  person  who  suffers  from  a  phagedenic  chancroid  be  inoculated  from 
a  simple  chancroid,  the  point  of  inoculation  will  at  once  take  on  the 
phagedenic  symptoms.  In  the  acute  form  the  phagedenic  chancroid 
resembles  an  intense  cellulitis  at  first.  The  deep  tissues  become  in- 
volved as  well  as  the  superficial,  the  parts  are  swollen,  oedematous,  and 
painful,  the  temperature  is  elevated,  the  pulse  rapid  and  feeble,  and 
the  tongue  dry  and  pasty.  Great  destruction  of  tissue  results,  large 
suppurating  cavities  form,  and  the  overlying  teguments  slough  away. 
The  lymphatics  in  the  vicinity  soon  become  involved  and  suppurate. 
Eollet  states  that  the  pus  from  these  buboes  is  not  auto-inoculable. 


VENEREAL  DISEASES   OF   THE  ANUS  AND   RECTUM  225 

but  this  statement  has  not  been  corroborated.  One  can  not  say  that 
these  general  symptoms  are  in  any  way  peculiar  to  chancroids.  They 
are  comparable  to  pygemia  and  due  to  the  absorption  of  pyogenic  bac- 
teria, which  are  always  present  in  chancroidal  ulcers. 

Metastatic  abscesses  may  form  in  any  portion  of  the  body,  and  unless 
the  disease  is  rapidly  checked  it  is  likely  to  prove  fatal.  Whsre  the 
patient  recovers,  it  is  generally  through  a  prolonged  convalescence  with 
resulting  large  cicatrices  in  the  region  of  the  sloughs. 

In  the  chronic  form  of  phagedenic  chancroid  the  onset  is  very 
insidious;  the  ulcer  first  shows  a  sluggishness  in  the  production  of 
healthy  granulations,  especially  at  one  or  the  other  of  its  borders.  At 
the  anus  it  has  a  tendency  to  extend  from  without  into  the  rectum. 
While  it  is  cicatrizing  at  one  area  it  advances  at  the  other.  There  are 
no  marked  constitutional  symptoms,  and  the  ulcer  is  less  painful  than 
acute  ulcerations  about  the  anus  usually  are.  The  lymphatic  engorge- 
ment is  less  marked  than  in  the  other  varieties  of  chancroids,  and 
suppuration  of  the  glands  is  unusual.  The  ulcer  tends  to  spread  super- 
ficially and  often  involves  only  the  mucous  and  submucous  tissues.  Oc- 
casionally, however,  it  may  involve  the  deeper  tissues,  and  cause  inflam- 
mation and  cellular  infiltration  of  the  muscles  that  surround  the  anus 
and  rectum.  It  is  only  in  these  rare  instances  in  which  the  ulceration  in- 
volves the  muscular  walls  that  chancroids  can  be  said  to  produce  a  stric- 
ture of  the  rectum.  Dupres  (Archiv.  J.  de  med.,  1868,  p.  257)  first  de- 
scribed this  condition  of  phagedenic  chancroid  as  an  etiological  factor 
in  the  production  of  stricture  of  the  rectum;  Mapon  (Amer.  J.  of  Med. 
Scs.,  1873,  p.  22)  wrote  in  confirmation  of  his  theory;  Van  Buren  (Dis- 
eases of  the  Eeetum,  1881,  p.  237)  stated  that  he  had  seen  a  chancroid 
of  the  anus  become  phagedenic,  extend  into  the  rectum,  and  at  a  later 
period  had  verified  the  existence  of  a  stricture  due  to  its  cicatrization; 
Bridge  (Archiv  de  Dermat.,  1876,  p.  122)  recorded  the  case  of  a  stric- 
ture of  the  rectum  due  to  chancroidal  ulcers  in  which  it  was  necessary  to 
perform  a  lumbar  colotomy  in  order  to  relieve  the  intestinal  obstruction. 

The  weight  of  evidence  seems  to  support  the  view  that  stricture  of 
the  rectum  may  be  produced  by  phagedenic  chancroids.  The  author 
has  seen  three  cases  of  chancroids  of  the  anus  which  had  left  contrac- 
tion of  that  orifice,  but  the  strictures  never  ascended  higher  than  the 
internal  sphincter,  and  could  not  therefore  properly  be  called  stric- 
tures of  the  rectum.  On  the  other  hand  all  of  these  cases  were  treated 
by  cauterization,  either  by  chemical  agents  or  the  actual  cautery,  and 
the  question  therefore  remains  in  doubt  whether  the  stricture  was  pro- 
duced by  the  cauterization  or  by  the  chancroid  itself. 

Treatment. — In  the  acute  variety  the  patient's  general  condition  is  of 
paramount  importance.  Abscesses  should  be  evacuated  as  soon  as  possi- 
15 


226  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

ble;  the  operator  should  he  very  careful  not  to  make  too  wide  incisions 
lest  he  open  up  healthy  tissues  for  infection  with  the  virus;  yet  neverthe^ 
less  the  inflamed  cellular  tissue  should  be  freely  incised.  After  the  ab- 
scesses have  been  opened  the  parts  should  be  frequently  irrigated  with 
antiseptic  solutions,  and  in  the  meantime  hot  poultices  should  be  applied 
in  order  to  increase  the  circulation  and  limit  the  sloughing  as  much 
as  possible.  The  temperature  should  be  controlled  either  by  cold 
sponging,  or,  if  necessary,  by  the  use  of  some  of  the  modern  antipyretics. 
These  latter  should  be  used  with  the  greatest  caution,  as  they  are  all 
depressing,  and  the  chief  difficulty  in  these  conditions  is  to  maintain 
the  patient's  strength  until  the  pysemic  processes  can  be  controlled. 
Tincture  of  the  chloride  of  iron  should  be  frequently  administered, 
and  bichloride  of  mercury  in  small  doses  will  generally  have  a  very 
good  effect.  Quinine  seems  to  act  well  in  some  cases,  while  in  others 
it  excites  the  patient  too  much  to  be  of  benefit. 

Assuming  the  condition  to  be  one  of  sepsis  due  to  the  absorption 
of  pyogenic  bacteria,  and  not  to  any  specific  chancroidal  virus,  one 
should  apply  the  principles  of  antiseptic  surgery  and  even  resort,  if 
necessary,  to  intravenous  saline  infusions  or  the  injection  of  antistrep- 
tococcus  serum. 

In  the  chronic  form  there  appears  to  be  a  local  condition  of  lowered 
vitality  in  the  parts.  The  fact  that  the  ulcer  heals  upon  one  border 
while  it  advances  upon  the  other  shows  that  the  tissues  of  the  latter 
have  less  power  of  resistance  than  those  of  the  former.  Where  a  well- 
developed,  healthy  granulation  is  once  established,  the  progress  of  the 
disease  in  that  direction  is  checked.  Sometimes  mild  astringent  or 
cauterizing  agents  suffice  to  produce  this  granulation  and  thus  check 
the  advances.  Nitrate  of  silver  may  be  tried  at  first,  and  following  this 
one  may  have  recourse  to  nitric  or  chromic  acid,  caustic  potash  or  acid 
nitrate  of  mercury,  or  finally  to  the  Paquelin  or  galvano-cautery  itself. 

The  modern  improvement  of  the  galvano-cautery  enables  us  to  apply 
it  now  at  every  point  in  the  circumference  of  the  rectum,  and  if  thor- 
oughly done  it  will  generally  check  the  disease.  This  application,  how- 
ever, is  not  without  its  dangers,  as  a  patient  has  died  from  shock  within 
a  few  hours  after  the  application  of  the  Paquelin  cautery  to  a  phage- 
denic chancroid.  One  should  therefore  prepare  his  patient  for  such 
an  ordeal  by  rest  in  bed,  general  constitutional  and  nerve  tonics,  and 
by  strong  stimulation. 

After  the  cauterization  the  parts  should  be  dressed  with  a  5-  to  10- 
per-cent  solution  of  picric  acid,  which  relieves  the  pain  of  burns. 

Maclaren  (Edinburgh  Clin,  and  Path.  J.,  183,  p.  697)  has  recorded 
the  case  of  a  woman  with  a  "  pellagrous,  phagedenic  chancroidal  ulcer  " 
which,  notwithstanding  cauterization  and  treatment  by  all  recognized 


VENEREAL  DISEASES   OF   THE  ANUS  AND  RECTUM  227 

methods,  continued  for  eight  years  -without  material  improvement.  It 
was  noticed  in  this  case  that  the  contact  of  the  menstrual  discharges 
with  the  parts  that  had  healed  immediately  caused  them  to  break  down 
again.  He  therefore  scraped  off  the  granulations,  dissected  out  the 
inflamed  tissues  beneath,  and  brought  the  parts  as  near  together  as 
possible  by  button  sutures.  After  this  the  vagina  was  tamponed  and 
kejDt  so  until  some  time  after  her  recovery,  particularly  at  the  menstrual 
periods.  Other  operators  have  not  been  so  successful  in  their  efforts 
to  check  phagedeena  by  excision.  The  experience  of  most  has  been 
that  the  fresh  edges  of  the  wound  rapidly  assumed  the  old  phagedenic 
condition,  and  the  area  of  the  ulcer  is  onW  increased.  On  the  whole 
one  must  largely  depend  upon  constitutional  treatment,  good  h3-giene, 
and  occasionally  the  application  of  the  actual  cautery  for  the  cure  of 
this  condition. 

Complications. — Chancroids  of  the  anus  and  rectum  may  be  com- 
plicated by  the  coexistence  of  true  Hunterian  chancre  in  the  same  lesion; 
but  mixed  sores  present  no  characteristic  features  at  first  beyond  those 
of  t}^ical  chancroids,  which  proceed  in  their  regular  course  for  some 
days  or  weeks,  when  the  bases  become  indurated  and  the  cicatrizing 
edges  undergo  cellular  infiltration.  At  the  same  time  the  ulcer  will 
secrete  more  pus  than  a  true  chancre  and  is  auto-inoculable. 

The  appearance  of  secondary  syphilis  is  the  pathognomonic  evidence 
of  the  combined  nature  of  the  sore. 

Chancroids  may  exist  in  connection  with  secondary  syphilis. 
S}^hilitic  ulcerations  and  even  broken-down  mucous  patches  may  re- 
semble chancroidal  ulcers  in  a  marked  degree,  and  as  these  ulcerations 
always  contain  pyogenic  germs,  auto-inoculation  may  produce  a  pus- 
tule and  yet  not  be  convincing  evidence  of  their  chancroidal  nature. 
On  the  other  hand,  if  one  assumes  in  these  cases  that  the  disease  is 
chancroidal,  he  may  overlook  the  sj^hilitic  nature  of  the  ulcers.  Anti- 
syphilitic  treatment  should  never  be  resorted  to  until  secondary  lesions 
appear  to  clear  up  this  confusion. 

The  occurrence  of  fistula,  fissures,  and  stricture  as  complications 
of  chancroidal  ulcers  have  been  mentioned.  There  is  one  form  of 
fistula,  however,  which  deserves  especial  mention.  In  chronic  chan- 
croids without  any  marked  phagedenic  tendency  about  the  anus  there 
occasionally  occur  small  subtegumentary  fistulee  that  extend  upward 
underneath  the  radial  folds  or  columns  of  Morgagni;  they  may  pene- 
trate the  mucous  membrane  above,  but  they  are  generally  of  the  incom- 
plete variety.  Wlien  the  chancroid  assumes  the  fissure-like  type  these 
little  fistulas  are  very  likely  to  be  overlooked  unless  the  parts  are  care- 
fully examined  with  a  very  fine  probe.  "WTien  they  are  not  recognized 
and  treated  the  discharge  from  them  keeps  up  the  ulceration  below  in 


228  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

spite  of  all  the  treatment  which  one  can  a})ply.  These  little  tracts 
should  be  laid  open  freely  and  cauterized  either  with  pure  carbolic 
acid  or  with  the  galvano-cautery.  The  reflex  complications  which  occur 
in  chancroids  of  the  anus  and  rectum  are  not  peculiar  to  this  particular 
form  of  ulceration;  they  occur  in  all  the  inflammatory  involvements  of 
these  organs  and  include  dysuria,  frequent  and  painful  urination,  irregu- 
larities of  the  menstrual  functions,  and  sometimes  in  pregnant  women 
who  have  no  symptoms  of  syphilis,  abortion. 


SYPHILIS 

This  protean  disease  manifests  itself  in  primary,  secondary,  and 
tertiary  lesions  in  the  skin  about  the  anus^  in  the  anal  canal^,  and 
within  the  rectum.  It  is  seen  at  all  ages  and  in  every  class  of  society. 
It  may  be  inherited  from  either  parent,  or  the  child  may  be  infected 
with  it  during  birth  through  the  presence  of  the  disease  in  the  mother's 
genitals.  It  is  acquired  through  natural  and  unnatural  vice,  through 
accidental  or  innocent  contact  with  diseased  persons,  or  indirectly 
through  the  use  of  toilet  articles  which  have  been  used  by  syphilitics. 

Chancre. — The  initial  lesion  of  syphilis  is  always  a  chancre.  It 
occurs  in  the  anus  somewhat  more  frequently  than  was  formerly  ad- 
mitted. Pean  and  ]\Ialassez,  combining  the  reports  of  Bassereau,  Four- 
nier,  Clerc,  Martin,  and  Carrier,  present  (Etude  clinique  sur  les  ulcera- 
tions annales,  Paris,  1871,  p.  88)  the  following  statistics:  In  1,237  extra- 
genital chancres  of  all  regions  in  men,  they  found  7  chancres  of  the 
anus,  in  175  in  women  there  were  14  chancres  of  the  anus.  From 
these  figures  it  would  appear  that  the  infection  occurs  at  the  anus  in 
1  out  of  177  cases  in  men  and  in  1  out  of  13  cases  in  women.  Sick 
(Jahrbiicher  der  Hamburgischen  Staats-Krankenanstalten,  1890,  t.  2, 
Leipsic,  1892,  p.  453),  in  summing  up  the  venereal  diseases  occurring  in 
the  general  hospital  of  Hamburg,  1880  to  1890,  found  in  9,881  males 
affected  with  venereal  diseases  1,010  mucous  patches,  1  true  chancre, 
and  1  chancroid  of  the  anus;  in  11,826  females  and  infants  affected 
with  the  same  diseases  there  were  986  mucous  patches,  9  true 
chancres,  and  224  chancroids  of  the  anus,  404  anal  fissures,  3  perineo- 
anal  chancres,  1  anal  gumma,  2  rectal  gummas,  and  10  strictures  of  the 
rectum. 

Salsotto,  quoted  by  Quenu  and  Hartmann,  found  in  201  extrageni- 
tal chancres  only  2  of  the  anus.  Jullien  (Traite  pratique  des  maladies 
veneriennes,  Paris,  1879,  p.  583)  found  11  chancres  of  the  anus  in 
2,171  cases  of  extragenital  chancres  in  men  and  39  in  473  cases  in 
women,  making  a  proportion  of  about  1  in  119  in  men  and  1  in  12  in 
women.     Quenu  and  Hartmann,  gathering  statistics  from  the  services 


VENEREAL   DISEASES  OF   THE  ANUS  AND  RECTUM  229 

of  Professor  Fournier,  of  Paris,  and  published  at  different  times  by  Nivet 
(These  de  Paris,  1886-1887,  No,  205),  Morel-Lavalles  (Annales  de  der- 
mat.  et  de  syphilog.,  1888,  p.  375),  Veslin  (Annales  de  dermat.  et  de 
syphilog.,  1890,  p.  317),  and  Feulard  (Annales  de  dermat.  et  de  syphilog., 
1890,  p.  320,  and  1892,  p.  805),  determine  that  in  778  extragenital 
chancres  there  occurred  52  chancres  of  the  anus,  of  which  26  were  lq 
males,  25  in  females,  and  1  in  an  infant.  Fournier's  latest  statistics 
(Les  Chancres  extra-genitaux,  1897,  p.  485)  give  in  a  total  of  10,000 
chancres,  58  of  the  anus  and  rectum,  37  being  in  men  and  15  in  women. 
The  proportion  in  the  two  sexes  is  1  in  192  cases  in  men  and  1  in  25 
cases  in  women.  Duhring,  of  Constantinople  (Gaz.  de  medic,  de  Paris, 
892,  p.  381),  states  that  out  of  42  extragenital  chancres  31  were  found 
about  the  anus  or  within  the  rectum;  what  is  still  more  remarkable  is 
the  fact  that  26  out  of  the  31  were  in  children,  and  of  the  5  in  adults 
4  were  in  males  and  1  in  a  woman.  The  disparity  between  these 
figures  and  those  of  Sick  seems  to  indicate  how  much  more  frequent 
is  the  practise  of  unnatural  vice  in  the  French  capital  than  in  its 
German  neighbor.  The  statistics  of  Duliring  from  the  Turkish  capital 
are  too  horrible  for  belief.  Pospellow  (Archiv  f.  Dermat.  u.  Syph., 
1889,  Nos.  1  and  2)  and  Neumann  (Wiener  medic.  Wochenschr.,  1890, 
No.  4)  found  in  282  cases  of  extragenital  chancre  8  chancres  of  the 
anus,  all  of  which  were  in  women.  In  over  3,000  cases  of  rectal  dis- 
eases treated  at  the  Polyclinic  Hospital  there  were  only  3  cases  of  true 
chancre  of  the  anus,  2  of  these  being  in  boys  and  the  other  in  a  woman. 
These  facts  show  that  except  in  those  countries  where  the  practise  of 
unnatural  vice  is  frequent  the  disease  is  very  rare  and  largely  confined 
to  the  female  sex.  This  is  also  in  keeping  with  the  anatomical  facts, 
as  referred  to  in  the  earlier  portions  of  this  chapter.  In  men  the 
occurrence  of  the  disease  in  these  locations  is  almost  positive  evidence 
of  the  practise  of  sodomy,  but  in  women  the  possibility  of  the  infection 
of  these  parts  through  their  contact  with  the  male  organ  or  through 
the  discharges  from  the  vagina  render  them  much  more  liable  to  anal 
chancres.  All  statistics,  however,  upon  this  subject  must  be  taken 
cum  grano  sails,  especially  in  men.  The  shame  of  such  practices  as 
cause  this  local  inoculation  in  males  deters  them  from  consulting  the 
doctor,  and  as  the  symptoms  are  not  unbearable,  probably  a  large  pro- 
portion of  them  are  never  seen.  Possibly  many  cases  of  secondary 
syphilis,  in  which  the  patient  denies  any  knowledge  whatever  of  the 
original  source  or  site  of  the  infection,  may  have  originated  in  true 
chancres  of  the  anus  or  rectum. 

The  initial  lesion  may  occur  in  the  skin  surrounding  the  anus, 
between  the  radial  folds,  in  the  anal  canal,  or  in  the  rectum  itself. 
Those  below  the  ano-rectal  line  are  termed  anal,  and  those  within  the 


230  THE  ANUS,   RECTUM,   AND   PELVIC  COLON 

sphincteric  contraction  above  this  line  are  termed  rectal  chancres.  The 
contagion,  as  admitted  by  most  observers,  is  carried  in  the  blood  and 
in  the  secretions  from  a  chancre  or  from  secondary  lesions;  the  normal 
secretions,  such  as  saliva,  sweat,  milk,  and  semen,  are  said  not  to  convey 
the  disease  unless  mixed  with  discharges  from  some  inflammatory  lesion. 
Whatever  the  source  of  the  contagion,  the  primary  infection  is  always 
a  true,  hard  chancre  at  the  seat  of  inoculation.  The  infection  may 
occur  through  immediate  contact,  and  generally  does  so  occur,  but  it 
may  also  be  brought  about  by  mediate  contagion,  such  as  the  use  of 
towels,  sponges,  cloths,  syringes,  etc.,  which  have  been  previously  used 
by  patients  affected  with  the  disease. 

The  author  saw  a  case  of  hard  chancre  of  the  anus  in  a  private 
patient  some  years  ago,  in  whom  the  disease  was  caused  by  the  use 
of  a  syringe  for  taking  a  rectal  enema,  the  instrument  having  been  used 
by  a  brother  who  was  suffering  from  constitutional  syphilis.  While 
such  instruments  may  be  used  with  impunity  so  long  as  there  is  no 
lesion  in  the  skin  or  mucous  membrane,  the  moment  they  come  in 
contact  with  a  fissure-like  crack,  an  abraded  hsemorrhoid,  or  a  small 
erosion  of  the  skin,  infection  is  very  likely  to  occur. 

Anal  Chancres. — The  most  common  seats  of  these  chancres  about 
the  anus  are  in  the  skin  just  outside  of  the  radial  folds  and  in  the  sulci 
between  these  folds.  A  sufficient  number  of  observations  of  this  char- 
acter has  not  been  made  to  Justify  any  generalization  with  regard  to 
the  comparative  frequency  in  location.  Of  three  cases  of  chancre  of 
the  anus  one  occurred  in  the  skin  just  below  the  radial  folds  and  the 
other  two  between  them.  Those  which  develop  upon  the  skin  around 
the  anus  do  not  differ  materially  from  the  cutaneous  chancres  on  other 
portions  of  the  body.  They  are  generally  superficial  and  circular  in 
the  first  stages,  resembling  abrasions;  their  bases  are  indurated,  the 
edges  red  but  not  infiltrated,  and  the  center  dark,  grayish,  and  some- 
times fissured.  After  they  have  existed  for  a  week  or  ten  days  the 
edges  become  infiltrated  and  the  whole  mass  hard,  indurated,  and  re- 
sisting. The  sores  are  said  to  be  painless,  but  there  is  always  more 
or  less  discomfort  produced  by  them  whether  upon  the  skin  or  muco- 
cutaneous border. 

When  they  occur  between  the  radial  folds  or  at  the  anal  margin  they 
usually  assume  the  shape  of  fissures.  The  distinction  between  them  and 
true  fissure  in  ano  is  said  by  Ball,  Quenu  and  Hartmann,  Allingham 
and  Kelsey,  to  be  easily  made,  owing  to  the  absence  of  pain  in  the  parts. 
Two  patients  affected  with  chancre  between  the  radial  folds  suffered 
just  as  acutely  after  movement  of  the  bowels  as  they  would  have  done 
from  any  other  fissures  of  the  same  extent  and  location.  The  only 
difference  between  these  ulcers  and  true  fissure  was  that  they  were 


YENEEEAL   DISEASES   OF   THE   AXES  AXD   RECTUM  231 

indurated  and  healed  rapidly  T\-itlioiit  even  stretching  the  sphincter; 
whereas  the  majority  of  true  fissures  have  no  such  tendency.  In  the 
first  stages  of  chancre  occurring  in  this  location  it  will  be  very  difficult 
to  decide  between  these  two  conditions,  as  the  induration  is  not  well 
marked  until  ten  days  or  two  weeks  after  the  development  of  the  initial 
lesion.  The  bases,  it  is  true,  are  hard  and  infiltrated  at  an  earlier  period, 
but  as  it  is  difficult  to  grasp  these  between  the  finger  they  give  the 
impression  of  cicatricial  thickening  rather  than  cellular  infiltration.  In 
one  chancre  between  the  folds  the  base  was  at  first  a  brownish-grav:  this, 
however,  soon  disappeared  and  left  a  bright-red,  granulating  surface 
which  bled  easily  upon  stretching  the  buttocks  apart.  In  both  these 
cases  the  chancre  healed  in  about  four  weeks,  and  in  four  cases  that  were 
observed  the  constitutional  symptoms  of  syphilis  developed  within  the 
first  eight  weeks. 

Where  the  chancre  occurs  a  little  higher  up,  or  intra-anal,  Hart- 
mann  states  that  the  patient  complains  of  a  sense  of  uneasiness  and 
discomiort,  never  of  an  acute  pain.  In  the  cases  that  occur  upon  the 
skin  and  between  the  radial  folds  one  may  see  the  lesions  by  gently 
separating  the  buttocks:  in  the  intra-anal  form  it  is  necessary  to  pull 
the  edges  of  the  anus  forcibly  apart  and  sometimes  even  to  use  a 
speculum  in  order  to  observe  them.  Here  the  chancre  assumes  the 
circular  or  round  form  at  first,  at  least  it  appears  so  when  the  parts  are 
stretched  open.  The  edges  are  slightly  elevated,  the  base  is  smooth 
and  indurated,  although  this  latter  condition,  it  is  said,  is  difficult 
to  make  out.  The  mucous  membrane  just  above  the  edges  of  the  ulcer 
appears  to  be  perfectly  healthy.  The  edges  of  the  ulcer  are  rose-colored, 
and  the  idcer  itself  secretes  a  very  scanty  muco-purulent  discharge, 
sometimes  slightly  tinged  with  blood.  If  the  discharge  is  abundant  it 
is  evidence  of  a  mixed  or  complicated  sore. 

Chancre  may  develop  upon  a  prolapsing  or  hypertrophied  external 
haemorrhoid  (Jullien).  In  such  cases  the  development  is  most  charac- 
teristic and  the  induration  very  great.  AYliere  the  chancre  involves 
the  muco-cutaneous  border  there  may  develop  intense  induration  of 
the  cutaneous  tissues  below,  even  almost  cartilaginous  in  its  nature 
(Neumann,  Annales  de  dermat.,  Paris,  1893,  p.  1326). 

Mixed  Sores. — Chancre  may  be  complicated  with  chancroid,  thus 
causing  a  mixed  sore,  as  has  been  described  in  a  preceding  section. 

Auto-inoculation  is  never  a  safe  diagnostic  g-uide  in  this  region  be- 
cause of  the  possible  presence  of  pyogenic  germs  in  the  ulcer  which  might 
make  it  successful  even  in  cases  of  true  chancre.  Simple  hard  chancres 
may  be  so  irritated  and  infected  by  the  passage  over  them  of  fsecal 
matter  that  they  assume  a  phagedenic  type  resembling  chancroidal  pha- 
gedsena.    Thus  one  must  admit  a  phagedenic  condition  as  complicating 


232  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

true  chancre,  such  as  is  described  by  Medina  (These,  Paris,  1891-92, 
No.  288),  and  Quenu  and  Hartmann  {loc.  cit.,  vol.  i,  p.  79). 

Course  of  the  Disease. — The  experience  of  Fournier,  Carrier,  and 
others,  who  state  that  tlie  course  of  these  local  sores  is  a  very  slow  one, 
has  not  been  confirmed ;  for  those  which  the  author  has  seen  have  healed 
comparatively  promptly.  They  say  that  the  parts  may  be  inflamed, 
assume  a  dark  venous  color,  sometimes  resembling  intertrigo,  the  radial 
folds  may  become  engorged,  and  in  the  midst  of  these  diffuse  lesions 
the  chancre  itself  may  be  passed  unobserved.  Such  a  diffused  conges- 
tion of  the  parts  must  be  very  rare,  and  would  indicate  to  the  writer  a 
mixed  infection. 

Sometimes  the  folds  bordering  upon  the  ulcer  become  hypertrophied 
and  develop  into  muco-cutaneous  tabs.  French  authors  speak  of  these 
as  condylomata.  On  this  side  of  the  Atlantic  the  term  is  not  used  with 
this  significance;  here  it  means  vegetating  excrescences  upon  the  skin 
or  mucous  membrane  which  have  a  warty  or  papillomatous  character. 
These  develop  about  the  anus  in  the  course  of  syphilis,  but  they  are 
among  the  secondary  manifestations  of  the  disease,  and  not  connected 
with  the  initial  lesion.  The  rapidity  with  which  the  chains  of  inguinal 
glands  upon  both  sides  of  the  body  become  successively  enlarged  is  one 
of  the  most  reliable  diagnostic  symptoms  of  chancre  of  the  anus.  The 
development  of  secondary  symptoms,  however,  is  the  only  absolute  proof 
with  the  initial  lesion. 

The  rapidity  with  which  the  chains  of  inguinal  glands  upon  both 
sides  of  the  body  become  successively  enlarged  is  one  of  the  most 
reliable  diagnostic  symptoms  of  chancre  of  the  anus.  The  develop- 
ment of  secondary  symptoms,  however,  is  the  only  absolute  proof  that 
any  given  sore  is  syphilitic.  Chancre  with  minor  degrees  of  hyper- 
trophy of  the  inguinal  glands  may  be  the  beginning  and  end  of  syphilis, 
or  a  patient  may  have  a  true  chancre  without  any  secondary  develop- 
ment, and  years  later  be  affected  with  a  true  outbreak  of  tertiary  syphi- 
lis; these  courses  indicate  that  the  systemic  resistance  at  the  time  was 
sufficient  to  overcome  the  virus  of  disease^  but  the  seeds  of  constitu- 
tional infection  remain  latent,  and  at  some  period  of  depressed  vitality 
overcome  this  resistance  and  develop  with  great  intensity.  At  other 
times  the  secondary  development  may  be  so  mild  that  it  does  not  make 
any  impression  on  the  patient,  and  passes  away  only  to  reappear  years 
afterward  in  the  shape  of  severe  tertiary  lesions.  These  facts  empha- 
size the  necessity  of  the  most  careful  observation  for  considerable  peri- 
ods of  time  after  a  suspected  sore,  and  also  to  guard  the  reader  against 
a  too  favorable  prognosis  in  any  such  case. 

Chancre  of  the  Rectum. — Chancre  of  the  rectum  proper  is  one  of 
the  rarest  of  diseases.    Martineau  (Legons  sur  les  deformations  vulvaire 


TENERBAL  DISEASES  OF  THE  ANUS  AND  RECTtJM  233 

et  anale,  1886,  pp.  153,  174,  176)  has  reported  three  cases^  1  entirely 
above  the  internal  sphincter,  1  on  its  level,  and  1  between  the  two 
sphincters.  Fournier  himself  says  that  he  has  seen  4  cases,  but  of  these 
the  diagnosis  was  absolutely  certain  in  but  1  (Les  Chancres  extra-geni- 
taux,  Paris,  1897,  p.  486).  Molliere  (loc  cit.,  p.  636)  only  credits  one 
of  these,  that  of  Fournier.  Ohmann-Dumesnil  (St.  Louis  Medical  and 
Surgical  Journal,  1900,  p.  294)  has  reported  two  chancres,  one  on  the 
verge  of  the  rectum  and  the  other  3  inches  above  the  anus,  both  in 
women.  Trelat  and  Vidal  de  Cassis  also  claim  to  have  seen  cases. 
Hartley  (Journal  of  Cutaneous  and  Genito-Urinary  Diseases,  1891,  p. 
218)  has  reported  a  most  carefully  observed  and  indubitable  case  as. 
follows: 

J.  McG.,  thirty-two,  male,  U.  S.,  organist,  was  admitted  to  tlie  Roosevelt 
Hospital,  September  20,  1890. 

Family  History. — No  tubercular,  renal,  or  cardiac  ailments.  No  rheumatic 
history. 

Personal  History,  ^-l^o  tubercular,  renal,  or  cardiac  disease.  Denies  all  pre- 
vious venereal  diseases.     Had  dysentery  some  years  ago. 

Present  Condition.— About  three  weeks  ago  the  patient  noticed  severe  pain  at 
defecation,  and  a  small  lump  just  within  the  anus;  pain  now  continuous;  tenes- 
mus after  each  passage ;  blood  has  been  present  at  stool  at  times.  He  has  suffered 
from  constipation  for  a  long  time. 

An  ulcer  is  found  just  1  inch  from  the  anal  margin.  It  is  about  the  size  of 
a  quarter  of  a  dollar.  The  base  is  indurated  and  the  ulceration  is  very  superficial. 
Sacral  glands  felt  enlarged.     There  is  no  evidence  of  any  other  lesion. 

Operation. — September  20th.  Usual  antisepsis.  Bichloride  and  boric-acid 
irrigation  of  the  rectum  ;  sphincter  dilated.  Bivalve  speculum  used.  The  ulcer 
is  seen  just  1  inch  within  the  rectum ;  it  is  superficially  eroded  with  a  distinct 
but  not  cartilaginous  base. 

Excision  of  Ulcer. — Cauterization  with  Paquelin  cautery.  Iodoform  powder. 
Suppository  of  opium,  gr.  ij ;  opium  pill,  gr.  j,  t.  i.  d.  Patient  ordered  to  wards 
and  to  be  watched  for  any  evidences  of  syphilis.  September  25th :  movement  of 
bowels;  daily  irrigation.  September  30th :  ulcers  healing  rapidly.  October  1st: 
roseola  over  tJie  surface  of  the  chest  and  abdomen.  October  5th :  discharged  from 
the  hospital  improved.  October  20th :  patient  applied  to-day  for  treatment  in  the 
out-patients'  department,  stating  that  his  medicine  had  been  used  up  and  that  he 
desired  more.  Patient  presents  a  papular  syphilide  involving  the  face,  forearm, 
trunk,  and  portions  of  the  extremities.  The  ulcer  of  the  rectum  is  healed. 
Patient  is  put  upon  antisyphilitic  treatment. 

A  careful  inquiry  as  to  the  mode  of  infection  was  instituted.  Patient  for  the 
first  time  during  his  treatment  here  admits  that  three  weeks  before  admission  to 
the  hospital,  while  in  Baltimore,  he  was  the  victim  of  another  man. 

After  this  confession  the  patient  was  lost  to  view. 

The  painlessness  of  the  lesion  described  by  some  authors  is  not 
borne  out  by  the  cases  of  Fournier  and  Hartley,  both  of  whose  patients 
complained  of  severe  pain,  the  sensation  of  a  lump  or  foreign  body 


234  THE  ANUS,  RECTUM,  AND  PELVIC  COLOX 

within  the  anus,  tenesmus  after  each  stool,  and  the  occasional  passage 
of  blood  with  the  faeces.  The  existence  of  chancre  within  the  rectum  is 
very  positive  evidence  of  sodomy,  although  it  is  possible  for  the  infec- 
tion to  occur,  as  in  the  case  of  anal  chancre,  through  the  use  of  an 
infected  syringe-tip. 

Symptoms. — The  symptoms  of  chancre  in  this  location,  as  drawn 
from  a  few  experiences,  are  more  or  less  acute  pain  at  the  time  of  or 
following  defecation;  a  discharge  of  muco-purulent  or  purulent  secre- 
tion, with  or  without  the  presence  of  blood.  Examination  gives  to  the 
finger  a  sensation  of  an  ulcer  slightly  depressed  in  the  center,  with 
clear-cut  borders  and  an  indurated  base.  These  ulcerations  are  very 
superficial.  The  sacral  glands  may  be  enlarged  if  the  sore  has  existed 
for  any  length  of  time.  One  would  not  expect  to  find  the  inguinal 
glands  enlarged  at  so  early  a  period  as  in  chancre  of  the  anus,  owing  to 
the  fact  that  the  lymphatics  above  the  sphincter  ascend  by  a  different 
route  from  those  below. 

The  histology  of  chancre  of  the  rectum  does  not  differ  from  that 
of  the  sore  found  elsewhere  except  in  the  tissues  involved. 

Treatment  of  Initial  Lesion. — The  treatment  of  chancres  of  the  anus 
and  rectum  is  practically  the  same  as  that  for  the  lesion  elsewhere, 
with  the  exception  that  in  these  locations  it  is  much  more  difficult  to 
keep  the  parts  clean,  and  it  is  more  usual  to  have  the  sore  complicated 
by  septic  conditions.  Great  care,  therefore,  is  necessary  to  avoid  these 
complications.  When  the  chancre  is  outside  of  the  anus  frequent  wash- 
ings with  antiseptic  solutions  should  always  be  practised.  After  the 
parts  have  been  thoroughlj^  cleansed  and  wiped  dry,  one  should  apply 
some  of  the  powders  mentioned  in  the  treatment  of  chancroid.  The 
mixture  of  equal  parts  of  oxide  of  zinc  and  calomel  is  excellent,  because 
it  is  devoid  of  any  disagreeable  odor,  it  is  inexpensive,  and  seems  quite 
as  effective  as  any  other  powder.  There  might  be  an  objection  to  the 
use  of  calomel  under  such  circumstances  because  of  the  possibility  of  its 
being  absorbed,  and  thus  masking  the  constitutional  syphilis  or  delay- 
ing its  appearance.  When  ulcerative  lesions  are  sluggish  and  inclined 
to  suppurate,  antinosin  or  tincture  of  iodine  stimulate  them  to  granu- 
lation, and  apparently  hasten  the  healing. 

After  the  powders  have  been  applied,  the  folds  of  the  buttocks  and 
the  radiating  folds  of  the  anus  should  be  carefully  separated  by  small 
pledgets  of  gauze  or  absorbent  cotton  to  prevent  the  friction  or  abra- 
sion occasioned  by  clothing  or  by  their  rubbing  together. 

When  the  chancre  is  well  within  the  anus  or  inside  of  the  rectum, 
it  will  be  necessary  to  introduce  a  speculum  in  order  to  cleanse  the  part 
thoroughly  and  apply  any  medication.  Under  such  circumstances  the 
fenestrated  conical  speculum  is  by  all  means  the  best,  as  it  can  be  intro- 


VENEEBAL  DISEASES  OF   THE  ANUS  AND  RECTUM  235 

duced  with  comparatively  little  pain,  and  the  remedial  measures  applied. 
Suppositories  containing  such  drugs  as  iodoform,  aristol,  and  noso- 
phene  will  be  advantageous  if  the  ulcer  is  well  within  the  rectum,  but 
useless  if  it  is  in  the  anal  canal.  The  bowels  should  be  kept  open,  but 
not  by  drastic  cathartics,  which  bring  on  diarrhoea  and  irritation  of  the 
rectum;  one  smooth,  gentle  movement  daily  is  the  most  satisfactory, 
and  this  can  be  obtained  by  a  morning  enema.  If  the  ulcer  is  in  the 
rectum,  it  may  be  necessary  to  use  opium  to  prevent  too  frequent 
stools.  Irrigation  of  the  rectum  by  boric  acid  or  mild  bichloride  solu- 
tions should  be  used  after  each  stool.  In  Hartley's  case  the  ulcer  was 
excised  and  the  base  cauterized  with  the  actual  cautery,  and  yet  secondary 
symptoms  promptly  appeared.  This  method  of  treatment  has  not  met 
with  the  general  approval  of  the  profession,  and  experience  with  it  has 
not  been  such  as  to  encourage  its  adoption  in  the  treatment  of  anal  or 
rectal  chancres.  If  kept  clean  and  dry,  and  the  patient  remains  quiet  for 
two  or  three  weeks,  these  lesions  will  generally  heal  and  leave  nothing 
more  than  an  indurated  spot,  which  gradually  disappears,  so  that  its 
site  is  unrecognizable. 

Secondary  Manifestations. — Secondary  syphilis  manifests  itself  in 
this  region  in  a  variety  of  ways.  Around  the  anus  one  may  observe  the 
same  lesions  which  occur  upon  the  skin  elsewhere  in  the  body.  They 
are  modified  to  a  certain  extent,  however,  by  the  close  approximation 
of  the  parts  and  their  habitually  moist  condition.  Thus,  the  macular, 
scaly,  moist  papular  and  tubercular  syphilides  in  this  region  are  very 
liable  to  be  transformed  into  mucous  patches  or  ulcerative  conditions. 
These  two  types  are  therefore  most  frequently  seen. 

Mucous  Patches. — Next  to  the  mouth  and  throat  the  anus  is  the 
most  frequent  seat  of  mucous  patches.  In  women  they  occur  at  some 
time  in  a  large  percentage  of  cases  of  constitutional  syphilis.  They  fre- 
quently begin  in  the  vulva  and  spread  to  the  anus,  but  it  is  not  at  all 
rare  to  see  the  first  patch  develop  in  the  latter  situation. 

The  course  of  their  development  is  as  follows :  There  is  first  an 
erythema  between  the  folds  of  the  buttock.  This  may  occur  even  before 
the  initial  lesion  heals;  when  the  latter  is  located  in  this  region  it  may 
imperceptibly  change  into  the  mucous  patch,  thus  occasioning  a  sort  of 
transformation  in  situ.  In  point  of  time  the  patch  corresponds  to  the 
macular  eruption  upon  the  skin.  It  appears  at  first  as  a  dull  red  zone, 
which  gradually  fades  into  the  surrounding  skin.  There  is  a  sort  of 
oedema  below  the  epidermis  which  elevates  the  epithelivm  above  the 
derma.  This  oedema  is  not  sufficient  to  produce  a  vesicle  or  bulla,  but 
the  epidermis  becomes  macerated  and  falls,  or  is  rubbed  off  by  the 
friction  of  the  parts,  leaving  a  superficial  erosion.  At  this  period  the 
condition  may  be  mistaken  for  an  acute  eczema.    There  is  little  itching, 


236  THE  AXUS,  RECTUM,  AND   PELVIC  COLON 

however,  the  discharge  is  scant  and  thin,  and  there  is  no  cracking  of 
the  tissues,  as  occurs  in  that  disease.  Soon  afterward  there  forms  upon 
the  surface  a  grayish-white  pellicle  or  membrane  somewhat  elevated 
above  the  level  of  the  skin.  The  cutaneous  tissue  beneath  this  is  infil- 
trated and  hypertrophied  in  the  superficial  layers.  These  changes  con- 
stitute the  mucous  patches.  They  may  be  single  or  aggregate,  and 
involve  the  entire  circumference  of  the  anus.  Generally  they  are  disk- 
shaped,  and  situated  upon  the  two  folds  of  the  buttock,  which  lie  in  con- 
tact with  one  another.  In  the  second  stage  the  patch  appears  as  a  sim- 
ple, elevated,  pearly  spot  situated  upon  a  supple  base  of  ver}'  slightly 
indurated  skdn,  and  is  termed  the  "  plaque  porcelainique."  As  the  con- 
dition develops,  the  patches  become  more  elevated,  but  are  pressed 
flat  by  the  buttocks,  and  secrete  a  thin,  fa?tid  fluid  which  keeps  the 
parts  moist  and  irritated.  In  tliis  stage,  on  account  of  their  flat  sur- 
face and  broad  bases,  they  are  termed  "  condvlomata  lata  "  (Plate  \,  Fig. 
1).  The  papillae  over  which  these  patches  are  situated,  through  cellular 
infiltration  and  irritation  by  these  secretions,  soon  begin  to  hypertrophy; 
the  branches  shoot  upward,  the  vessels  multiply  and  dilate,  the  summit 
of  the  growth  increases  in  weight,  while  the  base  remains  the  same, 
and  there  is  developed  a  cauliflower  gro-s^-th  distinguished  as  vegetating 
mucous  patches  or  venereal  warts.  This  condition,  while  due  originally 
to  specific  disease,  is  no  longer  a  purely  syphilitic  affection;  but,  on 
the  contrary,  a  papillomatous  growth,  which  does  not  yield  in  the  least 
to  internal  antisyphilitic  medication.  The  fact  that  the  secretion  from 
these  growths  is  auto-inoculable  would  seem  to  prove  their  non-syphi- 
litic nature.  "Within  the  rectum  mucous  patches  are  said  to  be  very  rare, 
but  the  author  believes  they  are  more  frequent  than  is  supposed.  Baren- 
spning  (Charite-AnnaL,  1885,  Bd.  vi,  p.  57)  long  ago  observed  them 
during  the  eruptive  stage  of  syphilis,  and  Muron  (Gazette  med.,  18T3, 
p.  8)  suggested  that  stricture  might  result  from  their  ulceration. 
Molliere  reported  a  case  in  which  the  patch  was  5  centimetres  above  the 
anus.  The  colored  drawing  (Plate  III,  Fig.  1)  shows  a  pear-shaped 
mucous  patch  on  the  middle  Houston's  fold,  which  was  demonstrated 
at  the  clinic  in  May,  1900.  They  give  rise  to  no  marked  s}Tnptoms,  and 
are  therefore  probably  overlooked. 

E.  Lang,  of  Innsbruck,  examined  110  cases  (45  men  and  65  women) 
in  the  eruptive  stage  of  s^i^hilis  with  reference  to  secondary  mani- 
festations of  the  disease  within  the  rectum.  He  found  plaques  or  papules 
in  16  cases.  They  were  located  generally  on  the  posterior  wall,  but 
sometimes  on  the  sides,  and  in  3  cases  involved  the  entire  circum- 
ference. The  plaques  were  frequently  ulcerated,  but  in  only  3  was 
there  pain  in  defecation  or  loss  of  blood.  In  1  case,  in  which  the 
plaque  was  situated  very  high,  the  patient  suffered  from  tenesmus  (E. 


VENEREAL  DISEASES   OF   THE  ANUS  AND  RECTUM  2Sl 

Lang,  Pathologie  unci  Therapie  der  Syphilis,  vol.  i,  p.  325).  This  expe- 
rience emphasizes  the  importance  of  early  rectal  examinations  in  con- 
stitutional syphilis,  and  proves  that  specific  ulcerations  often  occur  here 
unobserved  early  in  the  disease.  These  ulcerations  may  excite  inflam- 
matory processes  which  result  in  stricture  later  on.  Such  strictures, 
although  originating  in  s}^3hilitic  ulceration,  may  be  purely  fibrous  and 
possess  no  specific  pathological  characteristics,  such  as  gummata  and 
endarteritis. 

Small  Red  Papules. — Along  with,  or  sometimes  before  the  appear- 
ance of  the  mucous  patches,  there  may  occur  small  red  papules  around 
the  anus  or  between  the  radial  folds.  They  rapidly  break  down  and 
leave  small  ulcers,  which  assume  the  shape  of  fissures  when  they  occur 
in  the  latter  position.  These  fissure-like  ulcers  ma}^  also  occur  inde- 
pendently of  the  papules.  They  are  said  to  be  painless,  but  one  has 
to  see  only  a  few  such  cases  to  have  his  mind  disabused  of  any  such 
misconception.  They  are  distinguished  from  the  ordinary  fissure  by 
being  multiple,  of  a  grayish  color,  with  raised  edges,  slightly  indurated 
base,  and  by  the  existence  of  other  manifestations  of  syphilis  in  the 
individual.  In  one  case  a  small  red  papule  was  seen  1  inch  above  the 
sphincter. 

Seco7idary  Ulcerative  Lesions. — Between  the  secondary  and  ter- 
tiary ulcerations  of  the  anus  it  is  difficult  to  draw  the  line.  Lesions 
ordinarily  considered  to  be  secondary  may  come  on  years  after  the  in- 
fection. The  author  has  reported  elsewhere  a  typical  mucous  patch 
appearing  in  a  patient  nearly  four  years  after  the  initial  lesion,  and  as 
ulcerative  syphilides  are  later  manifestations  than  mucous  patches,  it  is 
reasonable  to  suppose  that  they  may  occur  at  even  more  remote  periods. 

Where  the  disease  runs  successively  through  the  primary,  secondary, 
and  tertiary  stages  it  fades  so  imperceptibly  from  one  into  the  other 
that  it  is  impossible  to  state  when  one  begins  and  the  other  ends.  As 
a  rule,  secondary  ulcerations  are  characterized  by  their  early  development, 
shallowness,  small  destruction  of  tissues,  and  healing  without  leaving 
cicatrices.  They  may,  however,  vary  in  these  respects,  sometimes  being 
very  destructive,  when  occurring  in  the  early  history  of  the  disease,  and 
at  other  times  they  may  occur  in  superficial  form  long  after  the  initial 
lesion  and  secondary  cutaneous  manifestations  have  passed  away.  Thus 
it  seems  that  the  character  of  the  ulcer  is  of  much  more  importance 
to  determine  the  stage  to  which  it  belongs  than  the  period  of  time  at 
which  it  appears,  and  ulcerations  having  secondary  characteristics,  as 
just  described,  may  occur  within  the  first  few  weeks  after  the  primary 
lesion,  or  even  3'ears  afterward,  and  clinically  and  histological^  they 
are  identical  in  both  periods.  They  are  secondary  ulcerations  at  what- 
ever period  of  the  disease  they  occur. 


238  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

The  method  of  their  development  is  various.  Tarnowsky  says : 
"  Where  a  constitutional  syphilis  exists,  but  without  any  positive  evi- 
dence of  the  disease,  an  abrasion  or  local  inflammation  may  take  on 
the  characteristics  of  syphilitic  ulceration,  and  healing,  leave  a  char- 
acteristic syphilitic  cicatrix,  smooth,  white,  depressed,  and  pigmented  at 
its  borders."  But  this  type  of  ulceration  ordinarily  occurs  in  the  ter- 
tiary stage. 

Mucous  patches  through  infection  or  the  virulence  of  the  disease 
may  break  down  and  leave  ragged  ulcers  about  the  anus,  such  as  the 
French  call  "  rhagades.'^  Papular,  macular,  and  pustular  syphilides, 
occurring  about  the  anus,  rapidly  become  ulcers.  They  may  also 
begin  as  local  inflammatory  effusions  or  cellular  infiltrations.  As 
these  increase  the  circulation  of  the  parts  becomes  choked,  the  tis- 
sues break  down,  and  there  results  an  irregular  ulcer,  gangrenous 
or  bright-red  in  color,  with  elevated  edges,  sometimes  bleeding  easily 
upon  touch,  and  comparatively  painless.  The  ulcers  are  frequently  mul- 
tiple, the  intervening  integument  being  perfectly  healthy;  when  they 
occur  between  the  radial  folds,  they  assume  the  elongated  appearance 
of  fissures,  the  folds  themselves  become  hypertrophied,  have  a  gray, 
sodden  appearance,  and  all  the  parts  are  bathed  in  a  thin,  purulent  secre- 
tion; in  these  sites  the  ulcers  are  not  painless — in  fact,  without  other 
evidence  of  syphilis,  one  could  scarcely  distinguish  them  from  simple 
fissures. 

Sometimes  the  anal  ulcers  extend  upward  and  involve  the  mucous 
membrane,  but  ordinarily  they  heal  or  remain  stationary  and  are 
chronic. 

7n  the  Rectum. — Above  the  ano-rectal  line  one  rarely  observes  any 
secondary  syphilitic  manifestations  other  than  the  ulcerative.  These 
lesions  may  be  either  single  or  multiple;  they  probably  begin  in  an 
abrasion,  then  follows  cellular  infiltration,  necrosis  of  the  tissues  and 
the  formation  of  small  crater-like  ulcers  with  clear-cut  indurated  borders ; 
they  rarely  extend  in  the  early  stages  deeper  than  the  submucous  tissue. 

Unfortunately  they  present  few  symptoms  at  this  time,  and  are  there- 
fore not  recognized  until  they  have  reached  the  chronic  stage,  when  they 
are  characterized  by  their  extensive  area  and  great  destruction  of  tis- 
sue. The  entire  thickness  of  the  wall  of  the  gut  may  be  destroyed  and 
the  sacrum  left  bare.  If  situated  upon  the  anterior  wall  of  the  rectum 
they  may  even  perforate  the  peritonaeum  (Molliere,  op.  cit.,  p.  645). 

The  tendency  of  all  syphilitic  ulcers  is  to  extend  in  the  line  of  the 
blood-vessels  and  lymphatics.  Thus  about  the  anus  they  progress  cir- 
cularly and  forward  toward  the  groins,  while  in  the  rectum  they  travel 
upward.  In  the  latter  position,  however,  owing  to  their  multiplicity,  they 
sometimes  coalesce  and  entirely  surround  the  organ.     In  ulcers  about 


VENEREAL  DISEASES   OF   THE  ANUS  AND   RECTUM  239 

the  anus,  the  lymphatics  of  the  inguinal  region  are  the  first  affected, 
while  in  ulcers  of  the  rectum  those  in  the  hollow  of  the  sacrum  become 
enlarged.  The  enlargement  of  these  latter  glands  must  not  be  mis- 
taken for  gummata.  If  the  ulceration  becomes  chronic  and  develops  ter- 
tiary characteristics,  as  it  progresses  upward  in  the  rectum,  it  often  heals 
at  the  lower  margin,  leaving  a  bluish-white  cicatrix.  The  walls  of  the 
rectum  beneath  the  ulcers  feel  leathery  and  parchment-like.  The  dis- 
charge is  greenish-yellow,  purulent,  tinged  with  blood,  and  very  abun- 
dant. Mucus  is  ordinarily  absent  from  the  stools.  The  odor  is  foetid 
and  disgusting,  but  distinctly  different  from  that  which  characterizes 
the  discharges  from  carcinoma. 

The  patient  suffers  from  tenesmus,  a  feeling  of  weight  and  pain 
about  the  sacrum,  and  frequent  stools.  He  m'ay  rest  fairly  well  at  night, 
but  upon  rising  in  the  morning  he  will  immediately  pass  a  large  quan- 
tity of  this  sanious  pus  from  the  rectum.  Later  in  the  day  he  may  have 
a  natural  movement,  but  at  various  times  throughout  the  twenty-four 
hours  he  will  be  called  to  the  closet,  only  to  repeat  his  early  morning  ex- 
perience of  passing  greater  or  less  quantities  of  this  greenish-yellow 
secretion. 

When  the  condition  has  existed  for  some  time  the  sphincters  become 
relaxed,  the  radial  folds  hypertrophy,  and  the  fluid  may  dribble  out 
through  the  anus,  keeping  the  parts  moist  and  irritated.  From  this 
irritation  there  may  develop  extensive  ulcers  about  the  anus.  When 
they  heal  they  sometimes  leave  a  ragged  condition  of  the  anal  folds 
resembling  a  cock's  comb,  but  not  so  red.  This  condition  has  been  con- 
sidered by  some  as  pathognomonic  evidence  of  syphilis.  Thus  Sir  James 
Paget  says :  "  I  will  not  venture  to  assert  that  these  cutaneous  growths 
are  never  found  except  in  syphilitic  disease  of  the  rectum,  but  they  are 
very  common  in  association  with  it,  and  so  rare  without  it  that  I  have 
not  seen  a  case  in  which  they  existed  either  alone  or  with  any  other 
disease  than  syphilis."  While  agreeing  in  the  main  with  what  this 
eminent  .surgeon  has  said,  the  author  still  believes  that  this  condition 
may  develop  from  other  inflammator}-  conditions  than  the  syphilitic. 

The  development  of  rectal  ulceration  in  the  early  stages  of  S3'phili3 
is  evidenced  by  the  following  brief  histories : 

J.,  thirty-two,  admitted  to  the  Workhouse  Hospital,  August  25,  1897. 
Family  history  clear.  Had  been  quite  well  all  her  life,  but  given  to  dissipation. 
Examination  showed  clearly  a  copper-colored,  macular  eruption  over  all  the  body 
and  upon  the  face.  She  admitted  having  had  a  vulvar  chancre  during  the  last 
week  in  June.  This  lasted  about  four  weeks,  and  healed  without  any  treatment, 
except  keeping  it  clean. 

Diagnosis. — Secondary  syphilis.     Treatment,  protoiodide  of  mercury. 

September  5th. — Patient  complained  of  aching  in  her  back,  diarrhoea,  and  pains 
shooting  down  her  legs.     Examination  showed  the  anus  perfectly  healthy,  even 


240  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

as  high  up  as  could  be  seen  by  forcibly  separating  the  radial  folds.  Upon  intro- 
ducing the  finger  into  the  rectum  a  shallow,  ulcerated  spot  with  an  indurated  base 
about  the  size  of  a  25-cent  piece  was  felt.  The  edges  were  not  particularly 
elevated,  and  the  mucous  membrane  around  the  ulcer  appeared  to  be  healthy. 
Through  the  speculum  the  ulcer  appeared  grayish-white  with  a  crater-like  base  and 
irregular,  clear-cut  edges.  It  involved  the  right  posterior  quadrant  of  the  rectal 
wall.  It  was  superficial,  bled  easily,  and  secreted  a  greenish-yellow  pus  in  abun- 
dance. The  eruption  was  still  present  upon  the  patient's  body.  The  sacral  glands 
were  enlarged,  as  were  also  the  epitrochlear  and  post-cervical.  The  inguinal 
glands  were  not  unusually  engorged.  The  ulceration  had  occurred  within  ten 
weeks  of  the  initial  lesion. 

The  following  history  of  another  case  seen  in  March,  1900,  in  the 
same  institution,  showed  that  the  rectal  ulceration  coexisted  with  a 
characteristic  secondary  eruption,  alopecia  and  mucous  patches  in  the 
throat : 

Lizzie ,  aged  twenty-four,  a  public  prostitute.     Family  history  indefinite, 

habits  vile.  Says  she  never  had  any  venereal  disease  until  six  weeks  previous, 
when  she  had  a  "breaking  out  on  her  privates." 

She  entered  the  hospital  February  28th,  complaining  of  great  pain  with  loss  of 
blood  at  each  defecation,  and  thought  she  was  suffering  from  piles.  At  the  same 
time  the  body  was  covered  with  papular  syphilides,  the  hair  came  out  easily,  and 
there  were  two  mucous  patches  in  her  throat.  Local  examination  showed  the 
radial  folds  of  the  anus  hypertrophied,  and  between  them  there  were  granulating 
fissures  which  bled  easily  upon  touch,  or  when  the  parts  were  forcibly  separated. 
There  were  no  mucous  patches  around  the  anus,  but  upon  introducing  the  finger 
into  the  rectum  there  was  found  an  ulcer  extending  upward  for  about  2  inches, 
almost  entirely  surrounding  the  rectum,  and  connected  below  with  the  fissures 
between  the  folds.  At  the  upper  end  the  ulcer  terminated  abruptly  in  healthy 
mucous  membrane.  The  base  was  hard  and  leathery,  the  edges  elevated  and 
indurated.     It  was  shallow,  and  bled  easily  upon  touch. 

In  this  case,  as  near  as  can  be  estimated,  the  rectal  ulcer  occurred 
within  eight  weeks  of  the  initial  lesion.  The  third  case  was  one  seen 
in  private  practice.  It  was  in  a  young  man  in  whom  the  initial  lesion 
occurred  on  the  lip.  The  induration  from  this  lesion  had  not  disap- 
peared at  the  time  of  the  examination,  although  the  sore  had  healed. 

He  had  at  the  time  of  examination  a  faint  copper-colored  eruption  upon  his 
body.  He  complained  of  heaviness  and  aching  about  the  anus,  pain  before  a 
movement  of  the  bowels,  and  a  discharge  of  pus  from  the  rectum,  especially  upon 
rising  in  the  morning.  The  anus  was  healthy  with  the  exception  of  hypertrophy 
in  two  of  the  radial  folds.  There  were  no  fissures  and  no  inflammatory  process 
apparent  upon  the  outside.  The  examination  of  the  rectum  showed  at  the  height 
of  1^  inches  a  distinct  ulceration  with  clear-cut  borders,  giving  to  the  finger  that 
leathery,  parchment-like  feeling  so  characteristic  of  syphilitic  lesions.  The  spec- 
ulum confirmed  the  impression  given  to  the  finger.  There  appeared  at  first  a 
profuse,  yellowish-green  purulent  secretion;  when  this  was  wiped  away  an  ellip- 
tical ulcer  was  seen  about  2  centimeters  long  and  1  wide.     It  was  nodular  and 


VENEREAL   DISEASES   OP  THE  ANUS  AND  RECTUM  241 

slightly  depressed,  the  edges  ipdurated,  but  not  much  elevated,  and  the  rectal 
wall  beneath  it  seemed  to  have  lost  its  supj^leness. 

He  stated  that  the  sore  on  his  lip  first  ajjpeared  eleven  weeks  before  consult- 
ing me. 

In  this  case  the  ulceration  occurred  within  twelve  weeks  after  the  initial  lesion. 

Numerous  cases  could  be  cited  in  which  the  ulcerations  have  oc- 
curred within  two,  three,  or  four  months  after  inoculation,  but  these 
appear  to  be  sufficient  to  establish  the  fact  that  they  do  occur  in  the 
early  secondary  stages  of  syphilis.  The  first  two  cases  left  the  institution 
much  improved  but  not  well,  and  it  is  impossible  to  say  what  was  the 
final  result  in  them.  In  the  last  case  the  patient  was  observed  for  over 
two  years,  and  there  was  never  the  slightest  evidence  of  any  stricture  of 
the  rectum,  showing  that,  if  these  ulcers  are  treated  in  their  early 
stages,  this  disastrous  complication  may  be  avoided. 

The  fact  that  one  can  not  obtain  the  history  of  initial  lesions,  pre- 
vious secondary  symptoms,  or  present  manifestations  of  the  specific  dis- 
ease, ought  not  to  deter  him  from  making  a  diagnosis  in  cases  of  char- 
acteristic syphilitic  ulceration  of  the  rectum,  such  as  the  following : 

Mrs.  S.  came  to  the  Polyclinic  Hospital,  October  15,  1895,  suffering  from  a 
profuse  rectal  discharge  which  she  said  had  existed  for  two  months.  There  was 
nothing  in  her  appearance  to  suggest  syphilis.  Her  husband  had  died  from  tuber- 
culosis one  year  previous.  She  denied  ever  having  suffered  from  any  skin  erup- 
tion or  any  local  ulceration.  Her  skin  was  clear,  and  there  was  no  marked  engorge- 
ment of  the  lymphatic  glands.  The  anus  was  normal  with  the  exception  of  hyper- 
trophied  radial  folds.  There  were  no  iilcers  between  these  folds.  The  sphincter 
was  relaxed  so  that  purulent  discharges  from  the  rectum  constantly  oozed  out, 
necessitating  the  wearing  of  a  napkin.  Examination  of  the  rectum  showed  exten- 
sive destruction  of  mucous  membrane  of  this  organ  as  high  as  4  inches  above 
the  anal  margin,  and  surrounding  the  entire  gut.  The  walls  were  stiff,  inelastic, 
and  nodular,  and  bled  easily  upon  touch.  The  rectal  ampulla  was  constantly 
ballooned,  but  there  was  no  contraction  of  the  caliber  of  the  gut  at  this  time. 
Around  the  lower  margins  of  the  ulceration  there  were  distinct  evidences  of  the 
healing  processes  in  the  existence  of  bluish-white,  depressed  cicatrices. 

The  discharge  was  a  yellowish-green  pus  tinged  with  blood,  and  very  abun- 
dant. At  first  tuberculosis  was  suspected  in  this  patient,  but  careful  examination, 
day  after  day,  failed  to  show  any  tubercle  bacilli.  Finally,  after  three  months, 
the  patient  consented  to  take  ether,  and  a  small  section  of  the  ulcerated  mucous 
membrane  was  removed  for  examination. 

Histological  report  by  William  Vissman,  M.  D. : 

"This  specimen  shows  the  epithelium  of  the  mucous  membrane  entirely  de- 
stroyed. The  Lieberkilhn  follicles  are  largely  obliterated,  there  being  a  few  small 
depressions,  which  appear  like  the  lower  end  of  such  follicles  lined  with  columnar 
epithelium.  There  is  an  intense  cellular  infiltration  of  the  submucous  tissues 
dipping  down  into  the  muscular  layers,  and  presenting  the  appearance  of  new- 
formed  fibrous  cells. 
16 


242  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

"  The  blood-vessels  show  distinct  endarteritis.  Embryonic  cells  are  distrib- 
uted along  the  whole  course  of  these  vessels,  and  at  no  place  are  there  any  giant- 
cells  or  tubercle  bacilli,  nor  are  there  any  accumulations  of  epithelium  which 
would  indicate  carcinoma.  On  the  whole,  one  would  describe  this  condition  as 
productive  inflammation  with  fibrous  and  cellular  infiltration.  This  is  a  condition 
frequently  found  in  chronic  syphilitic  inflammations." 

Antisyphilitic  treatment  was  begun  at  once,  but  too  late,  for  the 
patient  shortly  afterward  developed  a  papillo-squamous  eruption  all 
over  her  body,  on  the  palms  of  her  hands,  and  on  the  soles  of  her  feet; 
engorgement  of  the  cervical  glands  was  not  found  in  'his  patient. 
Either  the  woman  concealed  the  true  history  of  her  case,  or  it  consisted 
in  a  latent  form  of  syphilitic  infection,  which  first  exhibited  itself  in 
the  rectal  ulceration,  and  afterward  in  the  cutaneous  eruption.  Not- 
withstanding the  most  vigorous  antisyphilitic  treatment,  the  use  of  local 
remedies  and  constant  dilatation,  it  was  not  possible  to  prevent  contrac- 
ture in  her  rectum;  and  to-day,  after  seven  years,  she  still  has  some 
ulceration,  and  finds  it  necessary  to  pass  the  rectal  sound  twice  a  week  in 
order  to  keep  the  passage  open. 

The  author  had  under  his  charge  in  the  Polyclinic  Hospital  in  1901 
a  case  with  exactly  similar  conditions  in  the  rectum.  Her  ulcerations 
developed  about  nine  luonths  after  the  initial  lesion,  and  have  now  con- 
tinued for  two  years.  When  the  ulceration  has  reached  the  destructive 
stage  general  and  local  treatment  may  finally  heal  the  ulceris,  but  they 
can  not  prevent  the  formation  of  stricture.  The  prognosis  is  therefore 
always  grave. 

Treatment. — The  treatment  of  these  secondary  types  of  syphilitic 
inflammation  of  the  rectum  consists  in  the  administration  of  mercury 
and  keeping  the  parts  clean,  thus  avoiding  as  far  as  possible  any  sec- 
ondary infection  by  streptococcus  or  other  pyogenic  bacteria.  Like 
many  of  the  cutaneous  lesions  of  syphilis,  the  secondary  manifestations 
of  syphilis  in  the  rectum  will  sometimes  disappear  without  constitu- 
tional treatment  under  proper  antiseptic  care  of  the  parts,  but  medica- 
tion should  not  be  neglected.  A  large  number  of  destructive  ulcera- 
tions and  incurable  strictures  of  the  rectum,  called  syphilitic,  are  not 
due  so  much  to  the  syphilitic  virus  as  to  the  septic  infections  occurring 
through  the  lesions ;  becaiise  of  this  more  stress  is  laid  upon  the  local 
treatment  of  these  conditions  than  upon  the  constitutional.  This  sec- 
ondary infection  explains  also  the  statement  so  often  made  by  syphilog- 
raphers  and  proctologists  that  mercury  and  iodide  of  potash  have  little 
or  no  effect  upon  syphilitic  ulcerations  of  the  rectum. 

A  mixed  condition,  specific  and  septic,  must  be  dealt  with,  and  there- 
fore treatment  should  be  directed  in  two  lines.  Complete  drainage,  even 
if  the  sphincter  muscles  must  be  dilated  or  incised,  is  requisite  to  heal 


VENEREAL   DISEASES  OP   THE  ANUS  AND  RECTUM  243 

these  ulcers,  and  frequent  washings  and  dressings  are  important  in  order 
that  the  parts  may  be  kept  free  from  septic  bacteria.  To  accomplish 
this  the  patient  should  be  confined  to  bed,  if  possible  in  a  sanitarium  or 
hospital,  where  these  directions  can  be  systematically  carried  out. 

After  the  ulcers  have  been  thoroughly  washed  and  freed  from  the 
secretions,  they  should  be  dusted  over  with  some  drying  antiseptic 
powder,  as  antinosin,  iodoform,  aristol,  calomel,  or  boric  acid.  When 
calomel  is  used,  it  is  well  to  wash  the  parts  off  with  lime-water  after- 
ward, as  it  will  remove  the  particles  more  effectually  than  any  other 
fluid,  and  is  at  the  same  time  a  good  antiseptic.  Stimulation  of  the 
ulcerations  by  the  use  of  nitrate  of  silver,  sulphate  of  copper,  or  other 
agents  may  sometimes  be  necessary.  The  tubular  speculum  and  the 
knee-chest  posture  enable  one  to  insufflate  powders  upon  all  parts  of  the 
rectum  or  to  spray  them  with  various  medications.  The  bowels  should 
be  regulated  to  move  once  a  day  if  possible ;  the  administration  of  a  cer- 
tain amount  of  opium  to  control  the  tendency  to  diarrhoea  is  often 
advisable. 

The  constitutional  treatment  in  these  conditions  is  similar  to  that 
of  secondary  syphilis  in  any  other  portion  of  the  body.  It  consists  in 
the  administration  of  mercury  in  as  large  doses  as  the  patient  will  bear. 
In  rectal  syphilis  the  drug  should  be  given  by  inunctions,  baths,  or 
hypodermically,  as  the  internal  administration  is  likely  to  aggravate  the 
tendency  to  diarrhoea,  and  should  therefore  be  avoided.  Iodide  of  pot- 
ash in  this  stage  of  the  disease  is  advised  by  most  syphilographers,  though 
its  efficacy  is  questionable.  Mercury  is  probably  the  only  drug  which 
has  any  direct  effect  upon  the  specific  virus ;  the  iodide  acts  by  hasten- 
ing the  absorption  of  the  inflammatory  deposits,  but  probably  does  not 
affect  the  virus  itself.  Inasmuch,  therefore,  as  these  patients  usually 
suffer  from  digestive  disturbances,  it  is  best  to  refrain  from  using  this 
or  any  other  medication  by  the  stomach,  except  such  as  are  directed 
toward  the  improvement  of  functional  action  in  the  digestive  organs. 

Tertiary  Lesions. — The  chief  characteristics  of  tertiary  lesions  in  the 
rectum  are  as  follows: 

a.  They  develop  in  no  regular  order  with  relation  to  the  initial 
lesion;  they  may  come  on  immediately  after  the  secondary  eruption,  or 
months,  even  years  later;  indeed,  they  may  never  come  at  all. 

According  to  the  statistics  given  by  Morrow  {op.  cit.,  vol.  ii,  p.  139), 
they  only  occur  in  about  10  per  cent  of  the  cases  of  constitutional 
syphilis.  Of  this  number,  about  25  per  cent  occur  in  the  skin  and  the  rest 
in  the  nerves,  bones,  and  special  organs  of  the  body. 

h.  Another  characteristic  is  that  they  are  likely  to  be  recurrent. 
They  pass  away  or  are  dissipated  by  the  action  of  medicines,  and  at  long 
periods  thereafter  reappear  again. 


244  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

c.  They  are  loeolized,  involve  the  deeper  tissues,  are  destructive,  and 
leave  cicatrices  on  healing. 

d.  They  do  not  yield  readily  to  mercury. 

e.  They  are  only  mildly  contagious,  and  are  nearly  always  auto-in- 
oculable,  showing  that  the  ulcers  are  mixed  infections. 

The  chief  types  of  these  affections  are  gummata,  destructive  ulcera- 
tion, ano-rectal  syphiloma,  and  proliferating  proctitis. 

Gummata. — Gummata  may  occur  in  any  portion  of  the  body  in 
which  there  is  connective  tissue.  At  the  anus  they  are  exceedingly  rare, 
while  in  the  rectum  they  are  somewhat  more  frequent,  thus  reversing 
the  order  of  primary  and  secondary  lesions.  Fournier  states  that  he  has 
never  observed  a  gumma  of  the  anus  except  in  an  extension  of  gumma- 
tous ulcerations  occurring  in  the  neighborhood,  and  in  cases  of  ano-rectal 
syphiloma.  Molliere  (p.  641)  describes  a  gumma  occurring  primarily  at 
the  anus.  Verneuil  (Gazette  des  hopitaux,  1888,  p.  202)  has  reported  a 
most  interesting  case  of  this  kind  in  which  the  gumma  appeared  as  an 
induration  at  the  margin  of  the  anus,  about  the  size  of  a  small  orange, 
and  extending  across  the  ischio-rectal  fossa;  it  was  smooth,  elastic,  and 
painless  to  the  touch,  and,  believing  that  the  tumor  contained  pus,  he 
incised  it  with  a  bistoury,  but  obtained  nothing  beyond  a  discharge  of 
blood.  Some  days  afterward  suppuration  took  place,  and  a  fistula  re- 
sulted, for  which  an  operation  was  done.  The  ulceration  and  indura- 
tion having  persisted,  he  placed  the  patient  upon  antisyphilitic  treat- 
ment, and  obtained  a  complete  cure  after  a  limited  time.  This  case 
is  in  line  with  several  that  the  author  has  seen,  and  reported  under 
the  head  of  fistulee,  inasmuch  as  he  had  not  seen  them  in  the  gumma- 
tous stage.  There  were  induration  and  ulceration  of  the  wounds  with- 
out any  tendency  toward  healing  until  antispeeific  treatment  was  begun, 
after  which  it  progressed  promptly  enough.  A  number  of  times  nodu- 
lar deposits  beneath  the  radial  folds  of  the  anus  have  been  seen  in 
cases  of  tertiary  ulceration  of  the  rectum,  which  may  have  been  gum- 
mata, inasmuch  as  they  disappeared  under  the  influence  of  local  treat- 
ment to  the  ulcers  and  constitutional  treatment  for  the  disease;  they 
were  not  recognized  as  such,  however,  and  seemed  to  be  simply  inflam- 
matory deposits.  Taylor  (Journal  of  Cutaneous  and  Genito-Urinary 
Diseases,  1886,  p.  226)  records  a  case  in  which  the  gumma  was  situated 
in  the  recto-genital  saeptum. 

Gummata  within  the  rectum  have  been  reported  by  Bumstead  and 
Taylor  (Venereal  Diseases,  p.  607),  Ball  {op.  cit.,  225),  Zappula  (Archiv 
f.  Dermat.  und  Syphilog.,  Prague,  1871,  p.  62),  Poelchen  (Archiv  fiir 
Path,  und  Physiolog.,  Berlin,  1892,  p.  27),  and  Keuster  (ibid.,  p.  275).. 
In  one  case,  from  which  the  drawing  was  made  (Fig.  99),  the  patient  had 
suffered  from  syphilis  five  years  previously.    She  had  been  treated  at  the 


VENEREAL  DISEASES  OF   THE  ANUS  AND   RECTUM 


245 


time,  and  had  noticed  no  manifestations  during  the  three  years  preceding 
the  time  of  examination.  She  complained  of  pain  at  defecation,  bearing 
down,  and  the  feehng  as  if  some  foreign  body  was  in  the  rectum.  Ex- 
amination showed  a  dry,  brittle  condition  of  the  anal  mucous  membrane, 
with  some  haemorrhoids,  and  a  smooth,  globular  swelling  about  1  inch 
above  the  margin  of  the  anus,  freely  moYable  both  upon  the  muscular 


FlO.    99. — PHOTOillCEOGKAPH    OF    GuililA    OF    THE    EeCTUM. 


and  mucous  walls  of  the  gut.  An  operation  was  performed  to  overcome 
the  fissures,  the  hemorrhoids  were  removed,  and  the  little  nodular  swell- 
ing was  dissected  out. 

The  pathologist's  report  described  the  growth  as  typical  gummatous 
material,  with  granulation  tissue  in  all  stages  of  development.  The 
patient  was  at  once  put  upon  antisyphilitic  treatment,  and  the  operative 
wounds  all  healed  without  any  complication. 

In  the  case  of  Zappula  there  were  found  in  the  lower  portion  of  the 
rectum  some  globular,  smooth,  elastic  masses ;  at  a  distance  of  about  4 
centimeters  (If  inch)  above  the  anus  there  was  a  similar  mass  about 
the  size  of  a  small  hazelnut,  and  painless  to  the  touch;  there  was  no 
ulceration  and  no  cachexia.  The  diagnosis  was  properly  made,  and  the 
turners  disappeared  under  the  administration  of  iodide  of  potash.  He 
states  that  symptoms  of  absolute  obstruction  occurred  in  this  patient, 


246  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

but  it  is  difficult  to  understand  how  a  tumor  of  this  size  in  the  rectum 
could  possibly  occasion  it;  evidently  there  must  have  been  other  and 
larger  gummata  above,  or  the  symptoms  were  due  to  some  other  cause. 
Molliere  reported  a  case,  somewhat  similar  to  this,  in  which  the  gumma 
was  of  a  much  larger  size.  When  occurring  in  the  rectum  these  tumors 
appear  as  round,  elastic,  and  painless  deposits  in  the  submucous  tissues, 
and  in  their  early  stages  are  not  attached  to  either  the  mucous  or  muscu- 
lar wall  of  the  gut.  Later  on  they  may  involve  both.  They  are  gen- 
erally localized,  may  be  single  or  multiple,  and  of  any  size  from  a  hemp- 
seed  to  a  small  orange  (Poelchen's  Path.,  p.  51). 

There  is  no  marked  inflammatory  zone  about  them,  and  they  are  not 
accompanied  with  any  contractile  fibrous  bands  in  their  early  stages,  al- 
though there  may  be  a  slight  deposit  of  fibrous  tissue  in  the  neighbour- 
hood of  the  growth.  They  do  not  suppurate,  but  undergo  a  sort  of  fatty 
degeneration  according  to  Molliere,  and  thus  break  down.  The  facts  that 
they  do  not  produce  abscesses,  are  not  painful,  and  do  not  occur  in 
chains  distinguish  them  from  engorged  lymphatics.  When  they  break 
down  infection  takes  place,  causing  inflammation  and  an  increase  in 
the  inflammatory  deposit.  The  condition  thus  resolves  itself  into  an 
ulcer,  which,  healing,  leaves  a  contracting  cicatrix  that  may  cause 
stricture  of  the  rectum.  Temporary  stricture  of  slight  degree  may 
result  from  gummatous  infiltration  and  fibrous  deposit  around  it,  but 
these  strictures  do  not  become  permanent  unless  there  is  some  destruc- 
tion of  tissue  by  necrotic  or  ulcerative  processes.  All  the  reported  cases 
in  which  gummata  of  the  rectum  have  been  recognized  and  treated 
without  the  occurrence  of  ulceration,  have  recovered  without  leaving 
strictures.  Thus  one  may  refer  to  the  cases  of  Zappula,  Taylor,  Four- 
nier  and  Gant,  in  which  all  the  syphilitic  manifestations  disappeared 
under  general  treatment  and  left  no  contracture. 

When  gummata  disintegrate,  the  destruction  of  tissue  may  be  ex- 
tensive, sometimes  even  perforating  the  wall  of  the  gut;  if  this  occurs 
upon  the  anterior  wall  in  females,  it  may  result  in  recto-vaginal  fistula. 

Taylor  states  that  involvement  of  the  rectum  may  be  secondary  to 
an  "  indurated  oedema  "  following  infiltration  and  ulceration  of  the 
vulva  or  anus  early  or  late  in  the  disease;  that  ulceration  from  such 
conditions  resembles  the  chancroidal,  and  that  it  has  a  tendency  to  the 
production  of  rings  of  connective  tissue  about  the  rectum.  He  says  that 
these  rings  are  not  gummatous  in  their  nature,  and  the  induration  and 
swelling  occasioned  by  them  should  not  be  mistaken  for  this  form  of  the 
disease.  In  other  words,  they  are  simple  inflammatory  products  and  not 
syphilitic.  The  importance  of  this  statement  will  be  appreciated  when 
we  come  to  the  study  of  stricture  of  the  rectum,  and  learn  that  many 
strictures  in  syphilitics  are  not  syphilitic. 


VENEREAL   DISEASES  OF   THE  ANUS  AND  RECTUM  247 

Tertiary  Ulcerations. — One  of  the  most  frequent  manifestations  of 
tertiary  syphilis  is  a  dry,  brittle  condition  of  the  miico-cutaneous  tissue 
about  the  anus  resembling  that  seen  in  atrophic  catarrh.  Forcible  sepa- 
ration of  the  buttocks  or  stretching  of  the  anal  canal  in  these  cases  will 
produce  little  buttonhole-like  slits  in  the  membrane,  which  bleed  and  itch, 
but  do  not  cause  actual  pain.  The  passage  of  a  hard  stool  or  the  intro- 
duction of  a  bougie  will  cause  these  rents.  They  are  sometimes  points 
of  infection,  and  ulcerations  result  which  combine  both  specific  and 
septic  characteristics.  The  process  extends  upward  between  the  radial 
folds,  and  may  involve  the  mucous  membrane  of  the  rectum  to  an  in- 
definite height;  the  ulcers  may  become  phagedenic  and  result  in  great 
destruction  of  tissue,  as  in  the  case  of  Lane  (Lancet,  London,  1891, 
vol.  i,  p.  486),  where  almost  the  entire  perinseum,  together  with  the 
anal  and  vaginal  orifices,  were  destroyed,  notwithstanding  antisyphi- 
litic  medication. 

Tertiary  ulcerations  also  result  from  traumatism,  disintegrating 
gummata,  and  from  necrosis  of  tissue  due  to  occlusion  of  the  arterial 
supply  by  endarteritis. 

The  anus  and  rectum  are  subject  to  frequent  traumatisms  from 
hard  stools,  foreign  bodies,  etc. ;  in  women  they  are  often  injured  dur- 
ing coitus,  pregnancy,  and  childbirth;  all  such  injuries  may  take  on 
a  specific  nature  in  syphilitics.  That  they  do  not  yield  to  mercury  and 
iodides  is  due  to  their  constant  irritation  and  infection  by  the  faecal 
passages.  Such  ulcers  lose  their  specific  characteristics  under  specific 
treatment,  and  histological  examination  then  reveals  only  a  chronic 
inflammatory  condition;  those  due  to  gummata  and  endarteritis  usu- 
ally maintain  their  specific  characteristics  until  they  are  healed,  because 
the  process  is  more  deeply  seated  and  requires  a  longer  time  for  eradi- 
cation. 

Tertiary  ulcers  occur  most  frequently  just  within  the  rectum;  they 
are  deeper  than  the  secondary  ulcers,  are  crater-shaped,  have  3^ellow 
indurated  bases,  sharply  defined  borders,  and  are  rarely  ever  under- 
mined. Surrounding  and  beneath  them  the  rectal  wall  is  •  thickened, 
stiff,  and  inelastic,  which  condition,  when  it  involves  any  considerable 
portion  of  the  circumference,  sooner  or  later  results  in  stricture. 

Infection  is  an  important  element  in  their  tardy  healing,  and  may 
have  much  to  do  with  the  fibrous  deposit  that  causes  the  contracture. 
This,  together  with  systemic  conditions,  such  as  diabetes,  Bright's  dis- 
ease, and  tuberculosis,  is  accountable  for  those  widely  destructive  phage- 
denic conditions,  many  of  which  have  been  collected  and  reported  by 
Hahn  (Arch.  f.  Idin.  Chir.,  Berlin,  1883,  p.  395).  In  one  case,  seen 
some  years  since,  the  entire  anus  and  sphincters  were  destroyed,  the 
membranous  urethra  was  left  bare,  and  the  mucous  membrane  of  the 


24S  THE   AXUS.   RECTUM,   AND   PELVIC   COLON 

rectum  entirely  obliterated  to  the  height  of  over  6  inches.  Xotwith- 
standing  there  was  a  distinct  history  of  syphilis  in  this  case,  micro- 
scopic examination  of  the  specimen  removed  showed  only  chronic  inflam- 
mation, with  here  and  there  slight  endarteritis.  These  ulcers  not 
infrequently  perforate  the  rectal  wall  and  result  in  fistulas  of  various 
types,  which  do  not  differ  from  simple  fistulas  except  in  tardiness  of 
healing. 

The  suppuration  in  extensive  ulcerations  of  this  t3'pe  is  sometimes 
enormous.  Hahn  has  reported  a  case  in  which  it  amounted  to  a  liter 
per  day,  and  recently  in  the  Polyclinic  Hospital  a  case  was  treated  in 
which  it  was  almost  as  much.  The  odor  is  not  characteristic  as  in 
cancer. 

Ano-rectal  Syphiloma  of  Fournier. — Foumier  (Lesions  tertiaires 
de  Fanus  et  rectum,  Paris,  1875)  describes  under  the  above  heading  a 
specific  fibrous  infiltration  of  the  rectal  walls :  They  are  thickened,  mam- 
millated,  and  rigid  in  feeling,  without  any  ulceration.  He  states  that 
it  is  essentially  a  hyperplastic  proctitis  tending  to  sclerotic  change,  as  is 
seen  in  the  kidneys,  liver,  and  other  organs  in  late  syphilis.  It  begins 
in  the  submucous  tissue,  and,  according  to  him,  when  ulceration  occurs 
it  is  the  result  of  the  process  and  not  a  part  of  it.  He  says  (France 
medical,  October  31,  1874)  that  "  the  essential  redoubtable  phenomena 
upon  which  depends  all  the  evolution  of  this  pathological  process  is  a 
tendency  to  contract.  This  contracture  is,  by  virtue  of  its  fibrous  tissues, 
comparable  in  this  to  inodular  tissue,  that  it  retracts  without  cessation 
upon  itself."  Fournier  states  that  the  disease  is  always  due  to  acquired 
syphilis,  but  Ball  mentions  a  case  in  a  boy  ten  years  of  age  suffering 
from  congenital  syphilis.  Van  Harlingen  (International  Encyclopaedia 
of  Surgery,  vol.  ii,  p.  519)  claims  that  the  disease  rarely  extends  beyond 
2|  inches  from  the  anus.  This  limitation,  however,  is  not  corroborated 
by  other  observers.  Maclaren  (Edinburgh  Clin,  and  Path.  Jour.,  1883- 
'84,  p.  875)  considers  this  a  form  of  infiltrating  gumma.  His  micro- 
scopic reports,  however,  disprove  this,  for  he  says:  "  The  tumors  were 
composed  of  dense,  fibrous  tissue  sparingly  supplied  with  blood-vessels," 
a  condition  not  seen  in  gummata. 

The  majority  of  syphilographers  have  adopted  the  theor}'  of  Four- 
nier, and  the  weight  of  authority  is  therefore  in  its  favor.  They  state 
that  in  the  early  stages  it  produces  no  symptoms  such  as  pain,  discom- 
fort, or  obstruction  to  the  movement  of  the  bowels ;  that  the  only  method 
of  diagnosing  such  conditions  would  be  by  early  digital  examination, 
which  would  show  a  thickened,  infiltrated,  inelastic  condition  of  the 
rectal  wall  containing  more  or  less  nodular  masses  extending  for  sev- 
eral inches  upward  from  the  anus;  that  this  condition  proceeds  until 
constipation  from  gradual  contraction  of  the  rectum  results,  and  the 


VENEEEAL  DISEASES  OF   THE  ANUS  AND  EECTUM  249 

mucous  membrane  breaks  dc^vn,  owing  to  friction,  abrasion,  infection,  or 
some  interference  with  its  circulation.  According  to  this  theory  the 
stricture  occurs  firsts  and  the  ulcerations  which  follow  it  are  produced 
by  other  causes  than  the  actual  specific  disease.  There  is  no  authenti- 
cated report  of  the  careful  observation  of  such  a  course  of  events  in  a 
single  instance,  and  it  appears  to  the  author,  therefore,  as  purely  the- 
oretical. 

The  experiences  and  opinions  of  others  upon  this  condition  of  the 
rectum,  so  ably  described  and  defended  by  Fournier,  are  given  here, 
though  in  many  years'  experience  in  rectal  examinations  the  author  has 
never  observed  a  single  typical  case  of  this  ano-rectal  syphiloma.  He 
has  observed  a  number  of  cases  in  which  the  patient  had  suffered  from 
syphilitic  proctitis  and  ulceration  in  the  secondary  stages  of  the  disease, 
which  ulcerations  had  healed,  the  patients  had  thought  themselves  cured, 
and  discontinued  treatment,  but  afterward  found  that  the  disease  had 
returned  in  the  form  of  fibrous  infiltration  and  stricture  of  the  rectum. 
In  every  one  of  them  there  were  characteristic  bluish-white  cicatrices, 
and  the  ]3atients  gave  a  history  of  having  suffered  from  irritation  of  the 
rectum  and  a  discharge  of  mucus  or  pus  at  some  previous  time.  The 
condition  which  Fournier  described  exists,  but  it  is  associated  with  a 
history  or  evidence  of  a  previous  rectal  ulceration.  Fournier  alone 
positively  and  unequivocally  claims  to  have  observed  this  condition 
from  the  beginning,  and  even  his  reports  do  not  eliminate  the  possi- 
bility of  previous  ulceration.  Quenu  and  Hartmann,  in  their  excellent 
work,  cite  only  one  example  of  this  condition,  and  this  they  say  was 
preceded  by  syphilitic  ulceration  of  both  the  rectum  and  anus  {op.  cit., 
vol.  i,  p.  92).  It  seems,  therefore,  that  the  condition  originates  in 
specific  ulceration,  which  becomes  infected,  and  thus  sets  up  a  proctitis 
with  fibrous  infiltration.  In  proof  of  this  we  may  cite  the  fact  that 
mercury  and  iodides  have  no  effect  upon  it,  as  they  would  do  if  the 
infiltrate  were  syphilitic  in  its  nature. 

Proliferating  Proctitis. — Under  the  title  Eectitis  Proliferante  Syphi- 
litique,  Paul  Hamonic  (Annal.  med.  chir.  trans.,  France  et  etrang., 
1886,  vol.  ii,  p.  3)  has  described  a  condition  which  he  considers  a  pecul- 
iar syphilide.  The  disease  consists  in  a  growth  characterized  by  fragile 
villous  prolongations,  of  feeble  resistance,  from  the  mucous  membrane 
of  the  rectum.  In  the  cases  cited  the  tumors  filled  uj)  the  rectum, 
and  yet,  according  to  Hamonic,  they  did  not  tend  to  form  a  stric- 
ture. Kelsey  {op.  cit.,  p.  335)  has  detailed  a  case,  which  may  be  of 
this  same  character,  under  the  title  of  syphilitic  ulceration  of  the  rec- 
tum. The  author  has  also  reported  a  case  of  this  nature,  but  in  which 
true  obstruction  of  the  rectum  took  place.  Here  there  was  a  specific 
fibrous   stricture  underlying  the  hypertrophic  granulations   or  villous 


250  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

condition.  Such  a  state  of  affairs  may  be  brought  about  by  irritating 
discharges  from  specific  or  non-specific  ulcerations. 

In  the  author's  case  the  history  of  long-standing  ulceration  was  clear. 
The  condition  entirely  disappeared  under  antiseptic  and  antisyphilitic 
treatment  after  colostom}^,  but  left  only  a  narrow  fibrous  canal  where 
the  rectum  had  been. 

The  pathological  examination  of  all  these  ulcerated  types  of  syphilis 
of  the  rectum  shows  a  consistent  sequence  of  events;  first,  the  destruc- 
tion of  the  cylindrical  epithelium  of  the  mucous  membrane,  which  may 
afterward  be  replaced  by  a  corneous  or  pavement  epithelium  covering 
a  cicatrix  (Hartmann);  second,  a  cellular  infiltration  by  embryonic  ele- 
ments sometimes  containing  yellowish  nodules  of  a  gummatous  type, 
almost  surrounded  by  a  fibrous  or  sclerotic  zone.  In  the  early  stages 
the  blood-vessels  are  multiplied  and  dilated ;  in  the  later  stages  they  are 
decreased,  contracted,  and  always  present  evidences  of  endarteritis.  It 
is  simply  a  question  of  the  age  of  the  process,  whether  the  cells  are 
young  and  feeble  or  whether  they  are  old  and  surrounded  by  strong 
zones  of  sclerotic  tissue,  as  to  whether  it  can  be  resolved  or  not. 

Syphilitic  Stricture  of  the  Rectum. — Enough  has  been  said  above  to 
indicate  my  belief  that  unadulterated  syphilitic  strictures  of  the  rectum 
are  very  rare.  There  is  not  an  authentic  case  on  record  in  which  care- 
ful, systematic  examinations  throughout  the  early  stages  of  the  disease 
have  failed  to  show  ulceration  of  the  rectum  at  some  time  previous  to 
the  stricture.  Any  solution  of  continuity  in  the  mucous  membrane  of 
the  rectum  forms  an  open  doorway  for  septic  infection  and  consequent 
inflammation. 

While  we  know  that  a  large  number  of  strictures  of  this  organ  occur 
in  people  in  whom  there  is  a  more  or  less  distinct  history  of  constitu- 
tional syphilis,  yet  we  must  bear  in  mind  the  fact  that  because  a  patient 
once  had  syphilis  will  not  account  for  all  his  pathological  accidents  in 
after  life.  He  may  have  a  stricture  of  the  urethra,  the  rectum,  or  oesoph- 
agus, that  is  not  syphilitic  in  its  nature,  and  upon  which  antisyphilitic 
medication  will  not  have  the  least  effect.  Those  who  claim  that  this 
condition  is  due  to  a  primary  infiltration  of  the  rectal  walls  by  syphi- 
litic material  fail  to  fortify  their  opinions  by  a  record  of  careful  pre- 
liminary examinations.  Have  they  ever  examined  the  rectum  of  one 
of  these  cases  throughout  the  course  of  his  disease  a  month  or  a  year 
before  they  found  the  stricture?  All  admit  the  process  of  stricture 
formation  by  ulceration,  but  try  to  explain  away  the  complicating  effects 
of  infection  by  abstruse  theories  of  syphilitic  cellular  infiltration  of  the 
rectal  wall. 

The  first  stage  of  these  strictures  consists  in  an  ulceration,  trau- 
matic or  otherwise,  of  the  mucous  membrane.     This  is  followed  by  the 


VENEREAL  DISEASES  OF   THE  ANUS  AND  RECTUM  251 

deposit  of  a  soft  embryonic  tissue  in  the  submucous  wall  of  the  gut, 
together  with  infection  by  colon  bacilli  or  other  germs.  This  infiltra- 
tion and  infection  penetrate  downward  into  the  muscular  wall.  The 
mucous  membrane  may  reform  over  this  area,  producing  a  soft  cicatrix, 
over  which  the  epithelium,  changed  to  a  stratified  type,  is  established, 
and  presents  a  bluish-white  appearance.  This  cellular  infiltration  having 
once  penetrated  the  muscular  wall  of  the  gut,  finds  a  channel  of  least 
resistance  between  the  circular  fibers,  and  thus  gradually  infiltrates  the 
whole  circumference.  The  profound  infiltration  has  a  much  greater 
tendency  to  surround  the  gut  than  has  the  superficial,  because  in  the 
superficial  and  submucous  layers  it  follows  the  course  of  the  blood-ves- 
sels. Thus  we  sometimes  find  a  limited  ulceration  upon  the  wall  of  the 
intestine  with  an  extensive,  deep  infiltration  almost  surrounding  the 
gut.  In  the  early  stages  of  this  infiltration  these  tissues  are  soft  and 
dilatable.  They  also  yield  comparatively  good  results  to  the  adminis- 
tration of  antisyphilitic  medication  and  dilatation,  but  if  organization 
of  fibrous  tissue  has  taken  place,  if  the  muscular  fibres  have  become 
atrophied  or  transformed  into  fibrous  tissue,  medication  and  dilata- 
tion are  no  longer  permanently  effectual.  One  may  give  mercury 
and  iodide  and  stretch  the  parts  to  the  highest  limit,  but  they  will 
recontract. 

The  comparison  made  by  Monot  between  rectal  stricture  or  ano- 
rectal syphiloma  and  syphilitic  testicle  is  not  at  all  logical,  because  we 
have  to  deal  in  one  case  with  a  true  glandular  organ,  and  in  the  other 
with  a  muscular  and  mucous  membrane.  Injury  to  the  mucous  mem- 
brane, infection,  ulceration,  and  infiammatory  deposit  are  the  steps  in 
the  production  of  every  stricture,  and  in  the  syphilitic  this  inflammation 
takes  on  the  character  of  the  constitutional  disease — viz.,  gummatous 
deposits  and  endarteritis. 

For  the  pathology  and  further  consideration  of  syphilitic  stricture 
the  reader  is  referred  to  the  chapter  on  Strictures  of  the  Eectum. 

Treatment. — The  treatment  of  tertiary  syphilis  of  the  anus  and 
rectum  differs  from  that  of  the  disease  elsewhere  in  the  body  only  in 
the  management  of  the  local  conditions.  It  consists  in  the  adminis- 
tration of  the  iodides  in  as  full  doses  as  the  patient  can  bear,  inunc- 
tions or  hypodermic  injections  of  mercury,  and  the  topical  treatment 
of  local  conditions.  As  many  of  these  patients  suffer  from  digestive  dis- 
turbances, it  is  frequently  found  that  the  iodide  of  potash  aggravates 
these  conditions;  it  should  be  administered  in  milk,  the  essence  of  pep- 
sin, or  the  elixir  of  lactopeptine.  Giving  it  in  moderate  doses  and  fre- 
quently will  often  accomplish  better  results  than  a  few  large  doses  given 
in  water,  and  at  the  same  time  the  patient  is  being  nourished;  when 
milk  is  not  acceptable  to  the  individual,  the  iodide  can  be  dissolved  in 


252  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

it  and  then  converted  into  whey  by  the  addition  of  a  little  rennet.  The 
fluid  portion  of  this  whey  contains  practically  all  of  the  iodide,  and  is 
generally  well  borne  by  the  stomach.  The  iodide  of  potash  may  be 
alternated  with  the  iodides  of  sodium,  lithium,  and  strontium;  the 
amount  which  may  be  administered  in  a  day  is  very  variable:  some  pa- 
tients stand  exceedingly  large  doses,  while  others  can  take  only  moder- 
ate quantities;  in  general,  one  is  able  to  obtain  as  good  results  from 
60  to  100  grains  of  the  drug  per  day  as  from  the  enormous  doses  recom- 
mended in  certain  special  works. 

As  to  the  mercuric  inunctions,  the  methods  of  carrying  this  out 
are  described  in  all  books  upon  therapeutics  and  genito-urinary  diseases. 
Very  good  results  may  be  obtained  by  enclosing  3  or  4  drachms  of  mer- 
curic ointment  in  a  flannel  amulet,  which  is  fastened  around  the  pa- 
tient's neck  by  a  band,  thus  allowing  it  to  hang  about  the  middle  of  his 
chest  or  between  his  shoulder-blades ;  this  is  much  more  cleanly  than  the 
ordinar}'  inunctions,  and  seems  to  accomplish  as  good  results.  For 
h}-podermic  administration  bichloride  of  mercury  has  proved  most  satis- 
factor}',  but  salicylate  of  mercury  seems  to  be  very  effectual. 

The  local  treatment  of  the  different  manifestations  is  practically 
the  same  as  that  described  for  secondary  syphilis.  Eest  in  bed,  functional 
rest  to  the  parts  by  the  proper  regulation  of  the  bowels,  antiseptic  irri- 
gations or  washings,  and  occasionally  stimulation  by  mild  cauterizing 
agents  in  the  sluggish,  ulcerative  conditions,  are  the  general  lines  upon 
which  this  should  be  conducted.  When  there  is  extensive  ulceration 
and  profuse  purulent  discharge  from  the  rectum,  drainage  of  the  parts 
should  be  established  by  dilatation  of  the  sphincters,  and  if  necessary 
the  introduction  of  two  small  drainage-tubes  in  order  to  prevent  the 
accumulation  of  these  septic  discharges  in  the  ampulla.  With  the  two 
tubes  in  place  one  may  irrigate  the  parts  frequently  without  disturbing 
the  patient  very  much.  Solutions  of  benzo-naphthol,  boric  acid,  )8-naph- 
thol,  bichloride  of  mercury',  and  chloride  or  bicarbonate  of  sodium  are 
all  useful  for  this  purpose. 

The  dilatation  of  the  sphincter  should  be  gently  and  carefully  made 
so  as  to  produce  as  little  traumatism  as  possible.  The  swollen  hyper- 
trophied  folds  around  the  margin  of  the  anus  should  ordinarily  be  left 
alone,  as  they  will  largely  disappear  after  the  inflammatory  process  has 
subsided.  Condylomata  developing  around  the  anus  may  be  treated  by 
cutting  them  off  with  scissors,  cauterizing  them  with  the  actual  cautery, 
or,  better  still,  by  the  application  of  monochloracetic  acid,  followed  by 
some  drying  powder,  such  as  has  been  mentioned  before.  After  the 
ulcerations  have  begun  to  heal,  the  rectal  dilator  or  a  large-sized  bougie 
should  be  used  every  two  or  three  days  to  prevent  cofitraetion. 

In  tliose  severe  types  in  which  the  mucous  membrane  of  the  rectum 


PLATE 


MUCOUS   PATCH    ON 
HOUSTON    FOLD 


SYPHILITIC  STRICTURE 
(SEEN  THROUGH  PROCTOSCOPE) 


HEREDITARY   SYPHILITIC   FISSURE 


SYPHILITIC  AFFECTIONS  OF  THE  RECTUM 


VENEREAL   DISEASES   OP   THE   ANUS  AND   RECTUM  253 

is  practically  destroyed,  the  utmost  patience  and  perseverance  will  have 
to  be  exercised  by  both  doctor  and  patient ;  months  and  years  of  treat- 
ment are  necessary  to  heal  such  conditions. 

There  is  no  doubt  that  healing  may  be  hastened  by  absolute  rest 
through  the  production  of  an  artificial  anus,  a  proceeding  that  may  be 
justified  in  these  cases,  although  very  few  patients  will  submit  to  it.  It 
has  been  carried  out  by  Hartmann,  Hahn,  and  several  other  surgeons, 
and  the  author  has  treated  three  cases  in  this  manner,  all  of  which 
healed  finally  but  not  rapidly.  In  two  of  them  there  was  permanent 
stricture  left,  which  rendered  it  inadvisable  to  close  the  artificial  anus; 
in  the  other  the  ulceration  healed  in  about  three  months,  and  the 
colostomy  was  rejjaired  shortly  thereafter;  but  the  rectum  never  as- 
sumed its  normal,  smooth,  elastic  condition.  In  one  of  the  first  two 
cases  an  artificial  anus  had  been  made  and  closed  by  another  surgeon 
previous  to  my  seeing  her,  and  the  ulceration  and  stricture  of  the  rec- 
tum had  recurred  after  the  closure ;  so  it  was  best  to  make  a  permanent 
artificial  anus  after  Bailey's  method  in  her  case.  Such  experiences  lead 
to  the  conclusion  that,  while  these  ulcerations  heal  more  rapidly  by 
giving  the  parts  absolute  functional  rest,  at  the  same  time  one  should 
be  very  guarded  in  prognosis,  for  healing  even  under  these  circumstances 
is  slow,  and  the  condition  is  likely  to  recur  after  the  normal  channel  is 
reestablished. 

The  treatment  of  stricture  will  be  considered  in  the  chapter  upon 
that  subject,  and  the  methods  of  making  artificial  ani  can  be  found  in 
the  chapter  on  Colotomy. 

Hereditary  or  Congenital  Syphilis  of  the  Anus  and  Rectum. — Lesions 
of  the  anus  are  among  the  earliest  manifestations  of  hereditary  syphilis. 
They  may  occur  at  any  time  after  birth  up  to  several  years  of  age, 
but  the  most  frequent  period  at  which  they  are  observed  is  during  the 
first  three  months.  In  the  large  number  of  hereditary  syphilitics  which 
pass  through  the  eleemosynary  institutions  these  manifestations  about 
the  anus  are  unrecognized,  or  considered  simple  irritative  lesions  due  to 
lack  of  cleanliness  and  proper  diapers.  It  is  not  until  the  later  mani- 
festations of  hereditary  syphilis  appear  that  a  true  diagnosis  is  made 
in  the  majority  of  cases.  However,  there  are  instances  in  which  late 
secondary  cutaneous  and  osseous  lesions  have  occurred  in  infants  in 
whom  early  examination  had  failed  to  disclose  any  rectal  or  anal  affec- 
tions. On  the  other  hand,  over  50  per  cent  of  the  children  born  from 
syphilitic  parents  have  manifested  the  disease  within  the  first  six  months 
through  lesions  about  the  anus.  Besides  those  cases  in  which  the  parents 
were  known  to  be  syphilitic,  the  author  observed  in  his  clinic  for  diseases 
of  children  at  the  Korthern  Dispensary  of  New  York,  a  number  of  cases 
of  hereditary  anal  syphilis  in  infants  whose  mothers  were  free  from  any 


254  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

external  manifestations  of,  and  denied  having  suffered  from,  the  dis- 
ease ;  this  would  indicate,  of  course,  infection  from  the  father. 

The  disease  first  appears  in  children  as  a  sort  of  erythema  or  derma- 
titis around  the  anal  region,  which  may  occur  within  the  first  few  days 
of  life,  or  it  may  be  delayed  for  several  months.  Elsewhere  a  case  was 
reported  in  which  the  author  observed  this  erythema  at  the  age  of 
three  days  (Morrow's  System  of  Genito-Urinary  and  Cutaneous  Dis- 
eases, vol.  ii,  p.  436);  since  that  time  he  has  seen  a  child  aj)parently 
born  with  it,  as  the  condition  was  present  twenty-four  hours  after  birth. 
The  parents  of  this  child  were  both  syphilitics. 

The  erythema  is  often  accompanied  by  a  fragile  condition  of  the 
mucous  membrane  and  shallow  fissures  between  the  folds  of  the  anus. 
If  these  fissures  are  not  present,  they  may  be  produced  by  the  forcible 
separation  of  the  buttocks.  The  condition  is  very  easily  confounded 
with  that  irritated  condition  called  chafing,  which  is  produced  by  contact 
with  the  urine  and  faecal  materials ;  the  brittle  condition  of  the  mucous 
membrane,  however,  and  the  numerous  small  fissures  between  the  radial 
folds  will  serve  to  distinguish  these  two  conditions. 

In  the  early  stages  the  skin  is  slightly  pigmented,  red,  or  copper- 
colored  in  a  zone  extending  about  1  or  2  centimeters  around  the  anus ; 
but  after  a  few  days  the  skin  becomes  somewhat  thickened  and  elevated, 
and  thin,  sero-purulent  discharges  are  set  up,  which  soon  assume  a 
foetid  odor.  The  little  dry  fissures  do  not  extend  beyond  the  margin 
of  the  sphincter  in  this  early  stage,  but  if  the  condition  is  not  treated 
they  may  penetrate  the  anal  canal  itself,  become  infected,  and  develop 
into  progressive  ulceration  of  the  anus  and  rectum.  This  ulceration 
may  occur  within  the  first  three  or  four  months  of  life.  Little  fissures 
may  be  complicated  by  hypertrophy  of  the  radial  folds.  When  they 
have  existed  for  a  considerable  period  without  treatment  they  take  on 
the  characteristics  of  tn;e  fissure — i.  e.,  they  cause  pain,  burning,  and 
constipation  due  to  fear  of  going  to  stool  on  account  of  suffering.  A 
marked  instance  of  this  was  recently  observed  at  the  clinic. 

A  child  fifteen  months  old  suffered  from  constipation  and  little  in- 
flamed tabs  about  the  margin  of  the  anus.  It  had  typical  pigmentation 
and  induration  of  the  tissues  about  the  orifice.  The  mucous  membrane 
cracked  easily  at  various  points  upon  forcible  separation  of  the  but- 
tocks, the  inguinal  lymphatics  were  enlarged,  and  in  the  posterior  wall 
of  the  rectum,  about  3  inches  above  the  anus,  there  was  a  smooth,  round, 
elastic  deposit,  over  which  the  mucous  membrane  moved  easily,  and 
which  itself  could  be  moved  upon  the  muscular  wall.  There  were  no 
other  enlargements  above  or  below  it,  which  would  have  been  the  case 
in  all  probability  if  this  was  a  lymphatic  engorgement.  It  is  needless 
to  say  that  this  growth  was  a  true  gumma.    There  was  a  distinct  painful 


VENEREAL  DISEASES   OF   THE   ANUS  AND  RECTUM  255 

fissure  and  sentinel  pile,  which  the  illustration  shows  (Plate  III,  Fig.  3). 
If  the  diagnosis  of  these  erythematous  irritations  about  the  anus  be 
in  doubt,  and  if  the  history  of  the  case  does  not  justify  one  to  assume 
syphilis  to  be  the  etiological  factor  in  their  production,  he  may  wait 
for  the  development  of  other  symptoms  to  corroborate  his  opinion. 
Ordinarily  these  symptoms  are  not  slow  to  appear.  The  lack  of  normal 
development  in  the  patient,  the  appearances  of  the  squamous  lesions 
upon  the  soles  of  the  feet  and  in  the  palms  of  the  hands,  the  dry,  rigid 
condition  of  the  flexures  of  the  joints,  Hutchinson's  teeth,  and  fre- 
quently the  development  of  other  cutaneous  manifestations,  will  lead 
to  a  positive  diagnosis.  It  is  a  question,  however,  whether  in  such 
cases  one  had  better  not  adopt  the  principle  of  Wood,  and,  admitting 
that  there  is  a  possibility  of  hereditary  syphilis  in  every  child,  treat 
it  upon  that  principle,  and  give  the  innocent  babe  the  benefit  of  a 
doubt.  Delay  is  sometimes  disastrous;  whereas  in  most  of  the  cases 
in  which  the  condition  is  recognized  immediately  after  birth,  and 
treated  actively,  the  disease  can  be  mastered,  and  a  comparatively 
healthy  child  developed.  From  the  first  to  the  fourth  year  late  mani- 
festations of  syphilis  develop  in  hereditary  cases.  The  little  patient 
described  above  suffered  (so  his  mother  said)  with  redness  and  chafing 
about  the  anus  since  he  was  born,  though  there  had  never  been  any 
other  skin  lesions,  and  the  child  seemed  to  be  fairly  nourished.  He  had 
typical  Hutchinson  teeth  and  general  glandular  enlargements.  Aside 
from  this  and  the  anal  manifestations,  there  was  no  other  evidence  of 
syphilis.  The  mother  stated  that  the  father  had  suffered  from  breaking 
out  on  the  body  and  sore  throat  at  various  times. 

In  1893  a  child  two  years  of  age,  who  had  suffered  from  shortly  after 
birth  with  inflammation  about  the  rectum,  was  brought  to  the  clinic. 
This  child  not  only  had  induration,  thickening,  and  pigmentation  about 
the  anus,  but  also  ulcerative  lesions  about  the  folds  of  the  nates.  There 
was  an  inelastic,  leathery  condition  of  the  rectal  wall,  and  three  well- 
marked  gummata  in  the  organ.  There  were  also  crescentic  patches  of 
papular  syphilides  at  several  points  upon  the  body.  The  father  denied 
venereal  taint,  but  at  the  very  time  had  a  tertiary  eruption  upon  his 
body,  and  was  suffering  from  a  small  syphilitic  ulcer  in  the  rectum, 
which  he  supposed  was  an  inflamed  hemorrhoid.  I  have  followed  these 
cases  up  to  within  the  past  year.  The  father  is  apparently  perfectly 
well.  The  child  has  grown  to  be  a  healthy  maiden ;  the  induration  and 
thickening  of  the  rectum  have  entirely  disappeared,  and  one  could  not 
recognize  the  fact  of  her  ever  having  had  the  disease. 

Ball  (op.  cit.,  p.  184)  reports  a  case  in  a  child  ten  j^ears  of  age  in 
which  there  appeared  to  be  the  condition  known  as  ano-rectal  S3^philoma. 
In  the  chapter  on  Congenital  Malformations  reference  was  made  to 


256  THE   ANUS.   RECTUM,   AND   PELVIC   COLOX 

syphilis  as  an  etiological  factor  iu  the  production  of  congenital  stric- 
tures of  the  anus.  Bodenhamer  {op.  cit.,  p.  03)  looks  upon  this  as  an 
established  fact. 

Xot withstanding  the  majority  of  manifestations  of  syphilis  in  chil- 
dren are  hereditary,  one  ought  always  to  bear  in  mind  the  possi- 
bility' of  its  being  acquired.  Quenu  and  Hart  man  n  give  an  interest- 
ing case  of  this  kind^  in  which  a  child  of  two  years  of  age  passed 
through  a  t^-pical  sequence  of  early  and  late  secondary  syphilis,  fol- 
lowed by  well-developed  tertiary  symptoms.  The  father  of  this  child 
is  said  to  have  contracted  syphilis  after  the  child's  birth,  the  mother 
was  free  from  the  disease,  and  therefore  by  inference  the  authors  con- 
cluded that  it  was  a  case  of  acquired  primary  syphilis,  and  not  hereditary 
disease.  Bearing  upon  this  same  subject,  we  also  refer  once  more  to 
the  remarkable  statistics  of  Duhring,  of  Constantinople,  who  states  that 
out  of  31  chancres  of  the  anus  and  rectum,  26  were  in  children,  all  of 
which  must  have  been  acquired  and  not  hereditary.  Whether  these  in- 
fections were  due  to  accidents  or  unnatural  vice  the  author  fails  to 
state. 

Syphilitic  ulcerations  of  the  anus  and  rectum  in  children  do  not 
usually  involve  any  extensive  area,  nor  are  they  accompanied  with  any 
great  destruction  of  tissue;  the  process  seems  to  limit  itself  to  the 
cutaneous,  mucous,  and  the  immediate  underl3dng  tissues. 

Treatment. — The  constitutional  treatment  of  hereditary  syphilitic 
manifestations  about  the  anus  differs  in  no  wise  from  that  of  hereditary 
syphilis  in  other  portions  of  the  body. 

Mercuric  inunctions  either  through  the  stomach  bandage,  by  rubbing, 
or  through  the  wearing  of  the  amulet-like  bag  containing  mercuric  oint- 
ment, are  all  good,  and  should  be  persisted  in  for  long  periods.  Iodide  of 
potassium  or  other  salts  in  small  doses,  together  with  tonics,  especially 
hypophosphites  and  cod-liver  oil,  should  also  be  used. 

As  to  the  local  conditions  themselves,  applications  such  as  have 
been  mentioned  for  the  treatment  of  these  conditions  in  adults,  only  in 
milder  proportions,  should  be  adopted.  Equal  parts  of  glycerin  and 
cod-liver  oil  have  been  found  to  be  an  excellent  remedy  in  these  chil- 
dren, in  that  it  is  not  only  a  nourishment  and  a  tonic,  but  it  also  keeps 
the  faecal  movements  soft  and  regular. 

Prognosis. — The  prognosis  in  these  cases  is  variable.  Just  in  pro- 
portion to  the  early  recognition  and  radical  treatment  adopted  will  it 
be  good  or  bad.  The  majority  of  cases,  if  seen  and  treated  during  the 
first  two  or  three  months,  will  escape  all  later  manifestations  of  the 
disease.  In  some  children,  however,  the  general  vitality  is  so  feeble, 
even  at  the  time  of  birth,  that  no  treatment,  specific,  tonic,  or  other- 
wise, succeeds  in  establishing  good  health.     Especially  is  this  the  case 


VENEREAL  DISEASES  OF  THE  ANUS  AND  RECTUM  257 

in  foundling  asylums  and  eleemosynary  institutions,  where  the  lack  of 
proper  food  and  general  hygienic  surroundings  make  the  conditions  un- 
favorable. 

In  the  better  walks  of  life,  where  every  need  can  be  met,  and  every 
luxury  afforded,  these  children  generally  escape  the  manifestations  of 
the  disease,  owing  largely  to  the  fact  that  the  intelligence  and  general 
knowledge  of  their  parents  upon  these  subjects  lead  them  to  an  early 
recognition  of  their  responsibilities  in  the  case,  and  the  admission  of  the 
facts,  so  that  no  time  is  lost. 

In  the  lower  walks  of  life  ignorance,  carelessness,  and  lack  of  clean- 
liness all  contribute  to  negligence  and  late  recognition  of  the  child's 
condition ;  hence  the  prognosis  in  this  class  is  unfavorable. 


17 


CHAPTEE   VIII 

NON-SPECIFIC   ULCERATIONS 

The  term  non-specific  is  employed  here  simply  to  distinguish  the 
various  types  of  ulceration  from  the  venereal  and  tubercular  varieties. 
Many  of  them  may  be  due  to  just  as  specific  bacilli,  but  so  far  these 
have  not  been  isolated  and  specialized.  The  general  plan  already  out- 
lined will  be  followed,  and  the  subject  will  be  divided  into: 

Ulcerations  of  the  Perianal  Region. 

Ulcerations  of  the  Anal  Canal. 

Ulcerations  of  the  Rectum  and  Sigmoid. 

ULCERATIONS   OF   THE    PERIANAL    REGION 

Ulcerations  at  the  margin  of  the  anus  and  of  the  cutaneous  tissue 
surrounding  it  are  not  limited  to  any  age,  sex,  or  environment;  they 
are  more  frequently  found  in  those  in  the  lower  walks  of  life  where 
attention  to  hygiene  and  cleanliness  is  not  much  observed.  They  are 
due  to  traumatisms  followed  by  infection,  irritating  discharges  from 
the  anal  and  rectal  canals,  gonorrhoea,  chancroid,  chancre,  syphilis, 
herpes,  ringworm,  tuberculosis,  and  carcinoma. 

Traumatic  Ulceration. — Traumatic  ulcerations  of  the  perianal  region 
differ  from  cutaneous  ulcerations  elsewhere  in  the  body  only  insomuch 
as  they  are  influenced  by  the  anatomical  relations  of  the  parts.  While 
the  skin  upon  the  buttocks  is  tough  and  thick  and  the  epithelium 
horny  and  dry,  that  around  the  margin  of  the  anus  becomes  thinner 
and  thinner  as  it  approaches  the  muco-cutaneous  surface.  In  it  are 
embedded  sebaceous  and  hair  follicles,  together  with  many  sudoriferous 
glands  and  an  increase  of  pigment.  In  the  mouths  of  these  little  folli- 
cles and  glands  the  bacteria  and  bacilli  which  normally  inhabit  the 
intestinal  canal,  and  are  consequently  brushed  over  this  area  by  the 
faecal  passages,  find  a  habitat  and  are  always  present.  Any  traumatism 
or  abrasion  of  the  parts  therefore  becomes  easily  infected  and  an  ulcera- 
tion results,  the  progress  and  extent  of  which  will  depend  upon  the  care 
given  to  the  lesion,  the  vital  resistance,  and  general  constitutional  con- 
258 


NON-SPECIFIC  ULCERATIONS  259 

dition  of  the  invalid.  When  extreme  cleanliness  is  observed,  antisep- 
tics are  used,  and  the  parts  are  protected  from  constant  friction,  they 
generally  heal  kindly  in  individuals  otherwise  healthy;  under  other 
conditions  the  infection  becomes  progressive  and  they  may  extend 
over  large  areas. 

When  the  ulcer  originates  in  a  superficial  lesion  and  affects  the 
surface  of  the  skin  only,  it  will  ordinarily  limit  itself  to  these  tissues; 
but  those  due  to  furuncles  or  perianal  abscesses  may  extend  to  in- 
definite depths. 

Simple  ulcerations  are  due  to  infection  by  various  pyogenic  germs, 
inchiding  staphylococcus,  pyogenes  albus  or  colon  bacillus.  They  may 
be  single  or  multiple.  Their  shape  is  very  irregular;  the  edges  are 
red  but  not  much  inflamed,  and  gradually  slope  down  to  the  base, 
which  is  crater-shaped,  highly  granular,  sometimes  furrowed,  and 
bathed  in  a  purulent  discharge. 

There  are  no  constitutional  symptoms,  and  the  lymphatics  are 
rarely  involved.  Wiping  or  cleansing  the  parts  causes  a  blood}''  oozing. 
The  act  of  defecation  may  be  somewhat  uncomfortable,  but  does  not 
occasion  acute  pain;  sometimes  a  slight  bleeding  follows  it  owing  to 
the  abrasion  of  the  surface,  but  there  is  never  anything  like  a  haemor- 
rhage.    Pruritus  is  often  a  very  annoying  symptom. 

Little  abscesses  may  develop  in  the  deeper  layers  of  the  skin  owing 
to  infection  of  the  sebaceous  or  hair  follicles,  but  they  rarely  pene- 
trate the  subcutaneous  cellular  tissue. 

Treatment. — The  treatment  of  such  ulcerations  consists  in  the  pro- 
tection of  the  parts  from  friction  and  keeping  them  surgically  clean. 

In  the  first  stage  the  patient  should  be  kept  very  quiet  and  the 
parts  washed  frequently  with  permanganate  of  potash  or  peroxide  of 
hydrogen,  followed  by  a  l-to-2,000  solution  of  bichloride  of  mercury. 
A  pledget  of  gaiize  soaked  with  the  latter  solution  should  be  placed 
between  the  folds  of  the  buttocks  to  prevent  their  rubbing  against 
each  other  and  thus  developing  other  ulcers.  When  the  pruritus  is 
marked,  a  solution  of  methylene  blue  may  be  painted  over  the  parts 
once  in  twenty-four  hours. 

After  the  purulent  discharge  has  been  checked,  applications  of 
some  drpng  powder,  such  as  bismuth,  stearate  of  zinc,  or  nosophene 
may  be  employed.  A  mixture  of  equal  parts  of  starch  and  boric  acid 
is  a  very  good  and  inexpensive  application.  Where  the  ulcer  is  slug- 
gish and  disinclined  to  heal,  an  occasional  touching  of  the  parts  with 
tincture  of  iodine  or  nitrate  of  silver  will  hasten  the  process. 

Eegularity  in  the  fsecal  movements  and  attention  to  the  general 
constitutional  condition,  giving  tonics,  if  necessary,  and  regulating  the 
diet  by  wholesome,  non-irritating  foods,  will  generally  be  sufficient  in 


260  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

these  cases;  but  one  should  always  bear  in  mind  the  possibility  of 
secondary  infection  of  the  nicer  by  tid^ercle  bacilli. 

Herpetic  Ulceration  of  the  Anus — Herpes. — Herpes  is  not  fre- 
quently spoken  of  as  an  affection  of  the  rectum  and  anus.  This  is 
surprising  considering  the  number  of  cases  which  have  been  reported. 
Engle-Reimers  (Jahrbiicher  der  Hamburg.  Staats-Krankenanstalten, 
vol.  ii,  p.  98,  1890)  has  reported  25  cases  of  herpes  ani  that  occurred 
in  1,872  women  affected  with  venereal  disease. 

Syphilographers  in  general  acknowledge  its  frequent  appearance 
about  the  margin  of  the  anus.  While  it  is  not  generally  understood 
that  it  has  any  etiological  connection  with  syphilis  or  other  venereal 
affections,  it  occurs  frequently  upon  the  genital  organs  and  seems  to 
have  some  contagious  element.  It  occurs  at  the  margin  of  the  anus 
close  to  the  muco-cutaneous  border,  but  involves  the  skin  just  as  it 
does  at  the  margin  of  the  lips.  It  may  follow  malarial  fever,  acute 
attacks  of  indigestion,  or  occur  during  the  course  of  pregnancy. 

Pathology. — The  pathology  of  this  disease  is  not  clearly  understood. 
It  occurs  as  an  idiopathic  affection,  and  is  also  associated  with  many 
diverse  conditions.  It  may  be  due  to  a  neurosis,  to  local  irritation, 
or  to  a  special  parasite,  as  has  been  claimed  by  St.  Clair  Symmers 
(Brit.  Med.  J.,  December  19,  1891).  It  is  also  claimed  that  it  is  due 
to  rheumatism  or  gouty  diatheses,  but  this  seems  very  hypothetical. 

Symptoms. — Herpes  occurs  as  single  or  grouped  vesicles  over  which 
the  epidermis  is  elevated,  and  in  which  is  an  accumulation  of  clear 
or  milky-white  serum.  These  develop  after  a  slight  itching  or  burning 
sensation  in  the  parts.  They  sometimes  coalesce,  forming  one  large 
bleb,  around  which  there  may  be  considerable  oedema  of  the  tissues. 

Owing  to  the  contact  of  the  parts  these  blebs  soon  rupture  and 
leave  raw  surfaces.  They  do  not  bleed,  and  at  first  discharge  only  a 
serum  which  forms  a  sort  of  yellow  crust  over  them.  Tliis  soon  drops, 
however,  leaving  an  open  door  for  infection  by  the  germs  which  are 
always  present  in  the  skin  about  the  anus  or  in  the  faecal  passages; 
thus  an  ulceration  develops.  In  such  cases  the  herpetic  nature  disappears 
and  we  have  to  deal  with  a  simple  ulcer.  At  this  period  it  is  very  diffi- 
cult to  distinguish  the  disease  from  chancroid  or  even  true  chancre,  espe- 
cially if  the  parts  have  been  irritated  by  cauterants  or  acrid  discharges 
from  the  vagina.  It  may  generally  be  distinguished  by  the  period  of 
incubation,  slight  amount  of  induration,  lack  of  destructive  tendency, 
and  absence  of  glandular  involvement. 

Treatment. — When  seen  in  its  first  stages  treatment  is  always  rapidly 
effectual.  The  bleb  should  be  opened  and  its  thin  covering  excised, 
the  parts  should  be  washed  with  an  antiseptic  solution,  and  after  this 
a  soothing  drying  powder  should  be  applied.     Either  aristol  or  noso- 


NON-SPECIFIC   ULCERATIONS  261 

phene  act  extremely  well  in  herpetic  sores  because  they  absorb  moisture 
and  form  a  sort  of  protecting  shield  over  the  parts. 

The  prevention  of  relapses  is  of  paramount  importance  in  these 
cases.  The  vesicles  are  liable  to  return  on  the  slightest  provocation. 
The  parts  should  therefore  be  kept  scrupulously  clean  and  protected 
from  friction  by  pledgets  of  gauze.  They  should  be  bathed  in  as- 
tringent solutions,  such  as  alum,  tannic  acid,  and  sulphate  of  zinc,  to 
toughen  the  epidermis.  Quinine,  strychnine,  and  arsenic  should  also 
be  administered  for  their  effect  upon  malarial  and  nerve  complaints. 

Eczema  of  the  Anus. — Eczema  is  not  an  infrequent  affection  of  the 
anus.  Ordinarily  it  appears  under  the  erythematous  form  and  is  ac- 
companied by  superficial  fissures  radiating  from  the  center,  which  some- 
times extend  into  the  anal  canal.  It  is  very  often  associated  with  the 
same  type  on  the  scrotum  and  elsewhere  in  the  body. 

In  its  chronic  form  there  is  a  certain  amount  of  infiltration  of  the 
perianal  tissues.  The  skin  is  dry,  brittle,  and  easily  cracked  by  any 
stretching. 

The  term  moist  eczema  is  no  longer  recognized  by  dermatologists, 
but  there  sometimes  occurs  an  alteration  in  the  erythematous  form 
around  the  rectum  which  justifies  this  nomenclature. 

Vesicles  containing  serum,  such  as  are  described  under  the  title  of 
Eczema  Vesiculosum,  have  not  been  observed,  but  around  the  margin 
of  the  anus  and  between  the  folds  of  the  buttock  there  occurs  a  moist, 
red  condition  of  the  skin  following  the  original  erythema  and  charac- 
terized by  burning,  itching,  and  a  watery  discharge.  This  exudation 
possesses  that  gluey  character  which  stiffens  fabrics  and  gives  them  a 
slightly  yellowish  tinge  when  it  comes  in  contact  with  them.  It  is 
not  associated  with  any  formation  of  crusts,  probably  on  account  of  the 
close  apposition  of  the  parts,  which  prevents  rapid  evaporation.  On 
the  buttocks  and  in  the  perineal  and  coccygeal  sulci  this  moist,  exuding 
condition  gradually  fades  off  into  the  erythematous  form  upon  the 
scrotum  and  skin. 

For  the  etiology  of  this  disease  the  reader  must  consult  the  works  on 
dermatology. 

Treatment. — Attention  to  hygienic  conditions,  regulation  of  the 
bowels,  dietary  control,  and  the  internal  administration  of  such  medi- 
cines as  will  overcome  those  diathetic  conditions  characterized  by  de- 
ficient oxidation  and  imperfect  functional  action  of  the  organs  in  con- 
sequence, will  all  be  necessary  for  the  successful  treatment  of  this 
condition.  In  the  first  place  the  uricsemic  state,  if  present,  should  be 
attacked  by  the  administration  of  alkaline  diuretics,  the  flushing  out 
of  the  kidneys  with  large  quantities  of  water,  and  sometimes  one  will 
find  piperazine  a  prompt  and  effectual  remedy.     Arsenic,  sulphur,  and 


262  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

small  doses  of  iodide  of  potash  have  been  highly  recommended.  Pif- 
fard  speaks  in  glowing  terms  of  viola  tricolor  in  this  condition,  and 
states  that  it  has  a  decided  action  upon  the  kidneys,  to  which  is  proba- 
bly due  its  influence  upon  the  disease.  He  advises  its  use  in  small 
doses  in  acute  cases,  and  in  large  ones  in  chronic  conditions,  varying 
in  amount  from  one  drop  to  a  teaspoonful  according  to  the  age  of  the 
patient  and  the  chronicity  of  the  disease. 

As  to  the  local  treatment,  it  would  require  a  volume  to  even  mention 
the  many  combinations  and  preparations  suggested  for  the  treatment 
of  eczema  ani.  All  irritating  substances  should  be  avoided.  Hot  water 
applied  persistently  is  one  of  the  best  ways  of  relieving  the  congestion, 
itching,  and  irritation  of  the  parts,  and  to  this  one  may  add  a  small 
quantity  of  bicarbonate  of  soda.  Some  authors  strongly  disapprove  of 
washing  the  parts.  Frequent  scrubbing  and  friction  of  the  diseased 
area  is  objectionable,  but  the  application  of  hot  water  does  not  necessi- 
tate any  such  friction;  it  is  simply  daubed  on  with  a  soft  wad  of  gauze 
or  a  clean  sponge  and  held  to  the  parts  until  it  begins  to  cool  off,  when 
it  should  be  reapplied  as  hot  as  the  patient  can  bear  it. 

If  there  is  much  sero-purulent  discharge,  the  application  of  peroxide 
of  hydrogen  in  the  strength  of  10-  to  2o-volume  solutions  will  some- 
times rapidly  control  this  and  also  relieve  the  pain  and  itching.  The 
old-fashioned  blaekwash  is  very  effectual  in  the  relief  of  these  s}Tnp- 
toms.  Unguentum  zinci  oxidi,  unguentum  diachylon,  hydrargyri  am- 
moniati,  unguentum  picis  liquidi,  or  lanolin  in  which  is  incorporated 
a  small  percentage  of  bismuth,  salicylic  acid,  resorcin,  or  carbolic  acid, 
may  be  applied.  The  strength  and  selection  of  these  different  oint- 
ments will  depend  upon  the  individual  cases.  Some  are  found  in  which 
all  washes  and  oily  ointments  are  absolutely  irritating,  and  it  is  there- 
fore necessarv'  to  limit  ourselves  to  some  form  of  medicated  powder. 
Lycopodium  or  the  ordinary  talcum  toilet-powders,  the  subnitrate  of 
bismuth,  and  sometimes  dermatol  act  with  good  effect  upon  the  irritated 
conditions  of  eczema.  All  of  these  should  be  preceded  by  careful 
bathing  with  antiseptic  solutions  and  gently  drying  the  parts  with  soft 
absorbent  gauze  before  the  powders  are  applied.  Stearate  of  zinc  com- 
bined with  a  small  percentage  of  salol  or  aristol  is  very  soothing  to 
the  patient  and  productive  of  healing. 

Where  the  eczema  is  of  the  dry  variety,  with  thickening  and  infiltra- 
tion of  the  skin,  deep  fissures  and  puckering  of  the  mucous  membrane 
about  the  margin  of  the  anus,  a  more  active  treatment  may  be  necessary. 
Scarification  with  a  cold  or  hot  knife  are  inadvisable  because  infection 
and  deep  ulcers  are  likely  to  ensue.  The  fissures  should  be  touched 
with  strong  solutions  of  peroxide  of  hydrogen  or  with  the  actual  cau- 
tery, and  graphite  ointment  should  then  be  applied.    Ichthyol,  5  to  20 


NON-SPECIFIC  ULCERATIONS  263 

per  cent,  is  an  excellent  remedy  in  these  cases.  After  thickening  and 
infiltration  have  disappeared,  the  use  of  hot  water,  ointments,  and 
washes  as  advised  above  may  be  begun. 

Rodent  Ulcers. — Under  the  above  title  Allingham  originally  described 
a  number  of  ulcers  of  destructive  type  occurring  around  the  margin  of 
the  anus.  Among  these  he  included  a  number  which  were  of  a  distinctly 
tuberculous  nature.  In  the  last  edition  of  his  work  he  divides  these 
cases  into  two  classes,  the  lupoid  and  the  rodent  ulcers.  In  the  first 
class  he  describes  those  with  typical  tubercular  manifestations,  and  in 
which  tubercle  bacilli  can  be  demonstrated.  He  still  insists,  however, 
upon  the  occurrence  about  the  margin  of  the  anus  of  certain  character- 
istic ulcers,  which  are  neither  tubercular  nor  malignant.  He  states 
that  they  occur  in  otherwise  healthy  individuals;  that  the  edges  of  the 
ulcers,  although  hard  and  well  defined,  are  less  elevated,  and  the  bases 
more  indurated;  that  they  are  superficial  in  the  beginning,  but  have  a 
greater  tendency  to  extend  into  the  deeper  tissue ;  that  the  surfaces  are 
more  red  and  dry,  and  that  the  discharge  is  much  less  than  in  lupoid 
ulcers.  How  they  originate,  whether  in  traumatism,  moles,  warts,  or 
cellular  infiltration,  he  does  not  state.  The  description  given  resembles 
very  closely  the  typical  Jacob's  ulcer  or  lupus  exedens  of  dermatologists. 
This  type  of  ulceration  does  not  attack  the  mucous  or  muco-cutaneous 
borders.  They  are  ordinarily  described  as  attacking  the  skin  about  the 
face,  where  they  attain  considerable  size,  and  extend  down  to  the  bones 
themselves.  Dennis  states  that  they  begin  as  a  hyperplasia  of  the  epi- 
thelium belonging  to  the  sudoriparous  and  sebaceous  glands  or  the  hair 
follicles ;  that  the  pressure  of  this  hyperplasia  causes  atrophy  of  the  rete 
Malpighii,  but  not  degeneration ;  that  the  ulcers  differ  from  epithelioma 
in  that  the  lymphatic  nodes  are  less  liable  to  become  infected,  there  is 
none  of  that  typical  ingrowing  of  the  surface  epithelium,  and  the  cells 
are  smaller  and  the  nuclei  spindle-shaped. 

Fordyce  states  that  the  infiltration  at  the  base  of  these  ulcers  is 
always  less  than  in  true  epithelioma,  and  the  distinguishing  feature  be- 
tween the  two  is  the  disproportion  that  exists  between  the  ulceration  and 
the  new  growth. 

The  disease  always  occurs  late  in  life.  It  has  no  connection  with 
pulmonary  tuberculosis  or  any  other  constitutional  disease.  Its  course 
is  very  slow,  the  pain  is  limited,  and  the  lymphatics  are  seldom  involved. 
The  discharges  are  scant,  thin,  and  sanious.  The  ulcer  itself  is  harder 
than  the  lupoid,  but  there  does  not  exist  below  it  that  marked 
development  of  fibroid  or  cicatricial  tissue  which  characterizes  the 
latter  type. 

Histological  examination  shows  aggregations  of  epithelial  cells  ar- 
ranged symmetrically  throughout  the  structure.     The  capillary  blood- 


264  THE  ANUS,   RECTUM,  AND   PELVIC   COLON 

vessels  are  largely  increased,  but  there  is  no  marked  change  in  their 
walls.    Tubercle  bacilli  and  giant-cells  are  absent. 

From  these  facts  one  is  led  to  the  conclusion  that  this  type  of  ulcer- 
ation is  nothing  more  or  less  than  a  mild  form  of  epithelioma  modified 
by  senile  processes. 

Diagnosis. — It  is  almost  impossible  to  distinguish  these  ulcers  in 
their  early  stages  from  the  simple  tubercular  or  lupoid  types.  The  char- 
acteristics above  described  are  not  well  enough  marked.  They  so  closely 
resemble  the  other  varieties  that  one  would  not  be  justified  to  reach  a 
positive  conclusion  until  a  microscopic  examination  had  been  made,  and 
it  had  demonstrated  the  absence  of  tubercle  bacilli  and  giant-cells  with 
their  three  inflammatory  zones. 

Treatment. — As  the  rodent  ulcer  is  a  type  of  epithelial  growth,  its 
treatment  should  be  carried  out  upon  this  basis.  The  radical  excision 
of  the  tumor  will  appeal  to  every  surgeon;  however,  experience  with 
excision  of  epitheliomas  at  the  anal  margin  has  not  been  as  satisfactory 
as  could  be  wished,  because  there  seems  to  be  a  great  tendency  to  recur- 
rence. The  author  has  seen  but  one  removed  from  this  site  that  did 
not  return  within  two  years;  one  that  involved  the  margin  of  the  anus 
and  about  1  inch  of  the  mucous  membrane  was  removed  in  1894:,  and 
the  patient  remains  well  up  to  the  present  time,  but  four  others  re- 
moved since  that  time  have  recurred.  Eadical  cure  is  more  likely  to  be 
obtained  by  caustic  potash  or  arsenical  paste,  used  according  to  the 
methods  of  Eobinson,  who  has  been  so  successful  in  the  treatment  of 
these  conditions  upon  the  face.  There  is  no  reason  why  these  pastes 
should  not  be  applied  to  the  margin  of  the  anus  as  well  as  to  the  cheeks, 
lips,  and  facial  regions.  In  one  case  in  which  this  treatment  was  ap- 
plied the  results  were  very  satisfactory.  Local  and  internal  medication 
have  little  or  no  effect  upon  the  disease,  but  of  late  some  excellent  re- 
sults have  been  obtained  by  the  use  of  the  Eoentgen  rays  in  this  type  of 
ulcers. 

ULCERATIONS  OF  THE  ANAL  CANAL 

The  ulcerations  previously  mentioned  involve  the  cutaneous  tissues 
and  are  outside  of  the  influence  of  sphincteric  contraction. 

The  etiological  factors  in  the  present  type  are  practically  the  same  as 
of  those  in  the  perianal  region.  Chancres,  chancroids,  secondary  and 
tertiary  syphilis,  tuberculosis,  epithelioma,  traumatisms,  and  infections 
may  all  produce  ulceration  of  this  tract.  It  may  occur  through  exten- 
sion from  the  perianal  region  and  from  the  rectal  cavity  itself,  or  it  may 
originate  in  the  anal  canal.  Where  it  extends  from  the  perianal  region 
into  the  anal  canal  the  diagnosis  may  be  made  from  the  nature  of  the 
external  ulcer,  the  depth  and  extent  being  determined  by  digital  and 


NON-SPECIFIC   ULCERATIONS  265 

ocular  examination.  TThere  they  originate  in  the  rectum  it  is  much  more 
difficult,  as  the  nature  of  the  ulcer  below  may  be  entirely  different  from 
that  which  causes  it.  Carcinoma  and  stricture  of  the  rectum  are  often 
associated  with  simple  ulcer  of  the  anus. 

Most  ulcers  of  the  anal  canal  assume  the  form  of  fissures  at  first, 
and  present  the  same  symptoms — viz.,  pain  at  or  following  stool,  spasm 
of  the  sphincter,  bleeding,  and  suppuration.  The  typical  painful  ulcer  of 
the  anal  canal  is  a  fissure,  called  also  irritable  or  intolerable  ulcer,  which 
will  be  discussed  in  a  separate  chapter.  It  is  not  sufficient  that  a  pa- 
tient complains  of  pain,  sphincteric  spasm,  and  occasional  bleeding  to 
make  a  diagnosis  of  fissure  in  ano.  The  nature  of  the  ulcer  is  of  the 
utmost  importance  in  the  diagnosis  and  treatment.  Tuberculous,  epi- 
theliomatous,  and  venereal  ulcerations  between  the  radial  folds  of  the 
anus  may  all  produce  these  symptoms,  but  treating  them  as  such  would 
end  disastrously.  Traumatic  ulcers  that  follow  operations  or  injuries 
may  assume  the  shape  of  fissure,  but  without  the  characteristic  pain 
and  spasm  of  the  sphincter  one  would  not  characterize  them  as  such. 
They  are  simple,  non-irritable,  or  tolerable  ulcers.  In  many  of  these 
cases  the  sphincter  will  have  been  dilated  during  the  operations  which 
produced  them,  and  yet  there  will  remain  fissure-like  ulcers,  which  are 
slow  to  heal,  although  painless  and  without  any  hypertrophy  or  spasm 
of  the  muscle.  This  condition  is  due  to  repeated  infection  by  the  fascal 
passages.  In  distinction  from  true  fissure  none  of  these  ulcers  ordinarily 
occur  singly,  but  often  two,  three,  or  four  of  the  sulci  between  the  radial 
folds  are  affected  at  the  same  time.  Moreover,  they  generally  extend 
more  or  less  into  the  mucous  membrane  of  the  rectum  and  outward  upon 
the  cutaneous  tissue.  The  bases  are  not  indurated,  and  there  is  an 
abundant  purulent  discharge,  sometimes  tinged  with  blood,  which  is 
not  the  case  in  fissure. 

Another  fact  of  importance  is  that  in  simple,  venereal,  and  tubercu- 
lar ulcers  of  the  anal  canal  the  lesion  is  quite  as  frequently  upon  the 
sides  as  at  either  commissure  of  the  rectum,  whereas  in  true  fissure 
or  irritable  ulcer  the  lesion  in  85  per  cent  of  the  cases  is  situated 
unmediately  at  or  just  to  one  side  or  the  other  of  the  posterior 
median  line. 

The  S3Tnptoms  and  diagnosis  of  the  specific  forms  of  ulcer  will  be 
found  in  the  preceding  chapters. 

Simple  Ulcers  of  the  Anal  Canal. — As  just  stated,  these  are  usually 
due  to  extension  from  other  parts  or  to  traumatism  with  infection. 
They  may  affect  the  sulci  alone,  or  they  may  involve  all  the  circum- 
ference of  the  anus.  Such  ulcers  not  infrec[uently  follow  operations  for 
haemorrhoids,  especially  by  the  ^Yhitehead  method,  for  resection  of  the 
lower  end  of  the  rectum,  for  prolapse,  and  for  rectoeele.     They  do  not 


266  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

ordinarily  burrow  deeply,  but  in  healing,  especially  if  their  course  is  pro- 
tracted, they  are  very  likely  to  leave  fibrous  strictures. 

The  symptoms  are  tenderness  and  pain  at  stool  or  on  sitting  down, 
a  constant  discharge  of  pus,  and  gradually  increasing  difficulty  in  move- 
ment of  the  bowels.  Diarrlia?a  or  frequent  desire  to  defecate,  without 
satisfactory  results,  and  aching  pain  in  the  back  and  testicles,  are  often 
present.     Dysuria  is  frequently  an  annoying  symptom. 

Treatment. — Such  ulcers  are  often  very  difficult  to  heal  even  when 
the  sphincter  has  been  cut  or  stretched.  The  protection  of  the  parts 
against  constant  reinfection  is  not  easy.  An  oily  dressing  containing 
ichthyol  usually  accomplishes  this  as  well  as  any  other,  but  sometimes  an 
application  of  nitrate  of  silver,  after  thorough  cleansing  with  hydrogen 
peroxide,  will  form  an  albuminoid  coating,  which  acts  quite  well.  Moist 
absorbent  dressings  act  better  in  these  cases  than  drying  powders. 

Eest  in  bed  is  almost  a  prerequisite  for  cure,  and  if  the  hips  can 
be  kept  a  little  higher  than  the  chest  it  will  be  all  the  better.  Occa- 
sionally, however,  when  the  ulceration  surrounds  the  anal  canal  no  local 
treatment  seems  effectual,  notwithstanding  all  such  causes  as  syphilis, 
tuberculosis,  and  epithelioma  are  absent.  In  such  cases  one  may  suc- 
ceed by  dissecting  out  the  entire  ulcer  and  suturing  the  edges  of  the 
wound  together. 

ULCERATIONS    OF    THE    RECTUM    AND    SIGMOID 

The  rectum  is  very  frequently  the  seat  of  various  types  of  ulcera- 
tion, any  of  which  may  extend  into  the  sigmoid.  Traumatic  lesions, 
and  consequently  infected  ulcers,  are  much  less  frequent  in  the  latter. 
This  is  explained  by  the  fact  that  the  parts  are  in  relation  with  soft, 
elastic  tissues,  they  are  movable,  and  the  course  of  the  blood-vessels  is 
circular.  Thus  a  hard  faecal  mass  does  not  bruise  the  pelvic  colon,  as  it 
would  the  rectum ;  in  straining,  the  force  is  not  exerted  against  an 
immovable  and  resistant  wall,  as  in  the  rectum,  and  finally  the  sliding 
of  the  faecal  mass  over  the  surface,  the  erect  posture,  and  abdominal 
pressure  do  not  obstruct  the  circulation  and  cause  congestion,  as  they 
do  in  that  part  of  the  gut  where  the  vessels  run  up  and  down.  Aside 
from  the  traumatic,  pressure,  and  syphilitic  types,  however,  ulcerations 
are  quite  as  frequent  in  the  sigmoid  as  in  the  rectum.  The  two  parts 
are  so  inseparable,  and  the  pathology  and  s^anptomatology  so  similar, 
that  it  is  best  to  study  them  together,  always  bearing  in  mind,  however, 
the  differences  in  relationship  and  anatomical  construction. 

From  a  pathological  point  of  view,  and  for  convenience  of  descrip- 
tion, they  may  be  divided  into  simple,  specific,  and  systemic  ulcera- 
tions.    The  term  specific  is  still  used  here  in  the  broad  sense  in  which 


NOX-SPECIFIC   ULCERATIONS  267 

it  was  employed  at  the  beginning  of  this  chapter.  The  simple  ulcera- 
tions are  those  dne  to  traumatism  or  any  other  cause  followed  by  infec- 
tion from  the  bacteria  present  in  the  intestinal  canal.     They  are — 

1.  Traumatic. 

2.  Catarrhal. 

3.  Varicose. 

4.  Hemorrhoidal. 

5.  Follicular. 

6.  Strictural. 

The  specific  ulcers  are  those  due  to  infection  by  bacilli  not  nor- 
mally present  in  the  human  system.     They  are — 

1.  Tubercular. 

2.  Venereal. 

3.  Dysenteric. 

4.  Diphtheritic. 

5.  Carcinomatous  (?) 

The  systemic  t5''pes  are  those  due,  or  at  least  secondar}^  to  grave 
constitutional  or  organic  diseases.     They  are — 

1.  iSTephritic. 

2.  Diabetic. 

3.  Trophic. 

4.  Hepatic. 

5.  Marasmic. 

Some  of  these  divisions  overlap  one  another  in  a  measure,  as  both 
pathological  conditions  may  be  present  in  the  same  individual  and 
operative  at  the  same  time  in  the  production  of  ulceration.  In  such 
cases  there  may  be  two  distinct  ulcers  present  in  the  same  rectum,  or 
we  may  have  the  two  types  combined  there,  forming  a  sort  of  mixed 
■ulcer.  Thus  there  may  be  simple  ulceration  of  the  mucous  membrane 
along  with  carcinomatous  involvement  of  the  rectum  at  a  higher  point. 
Catarrhal,  hgemorrhoidal,  and  specific  ulcerations  may  be  all  present  at 
the  same  time  in  one  individual.  A  simple  traumatic  ulcer  may  become 
infected  by  tuberculosis  or  syphilis,  and  thus  its  nature  will  be  entirely 
changed  from  what  it  was  when  first  observed.  It  will  be  impossible 
to  repeat  these  complications  under  every  type  of  ulceration,  but  the 
reader  should  constantly  bear  them  in  mind,  and  in  clinical  work  apply 
the  diagnostic  tests  in  every  case. 

The  specific  ulcerations  having  already  been  described,  the  simple 
and  systemic  t}^es  will  be  considered. 

Etiology. — Certain  predisposing  causes  and  S3Tnptoms  are  common 
to  many  if  not  all  types  of  ulceration  in  the  rectum  and  sigmoid.  They 
may  therefore  be  enumerated  here  once  for  all,  and  referred  to  under 
the  special  varieties  in  order  to  avoid  repetition. 


268  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

Predisposing  Causes. — Age :  Kectal  ulcerations  are  rare  in  very 
young  children,  but  in  old  people  those  types  due  to  pressure,  varicose 
veins,  and  trophic  changes  are  quite  frequent.  The  condition,  however, 
is  much  more  frequently  seen  in  middle  life.  This  may  be  due  in  part 
to  the  preponderance  in  numbers  at  this  age  over  the  very  old,  but  it  is 
also  influenced  by  the  more  constant  straining  at  exercise  or  labor,  ex- 
posure to  accidents  or  injuries,  and  the  frequency  of  surgical  opera- 
tions. In  women  the  menstrual  and  child-bearing  periods  also  pre- 
dispose to  it. 

Sex:  Women  are  more  subject  to  ulceration  of  the  rectum  on  ac- 
count of  the  greater  frequency  of  constipation,  pressure  on  the  organ 
by  misplaced  or  gravid  uteri,  tumors,  badly  fitting  pessaries,  and  in- 
juries during  childbirth;  also  from  the  exposure  of  the  organ  to  the 
acrid  and  irritating  discharges  from  the  vagina.  The  influence  of  these 
conditions,  together  with  the  various  inflammations  of  the  reproductive 
organs  and  pelvic  cellulitis  in  the  production  of  rectal  and  sigmoidal 
disease,  is  not  sufficiently  appreciated.  Many  cases  of  pelvic  disease 
in  women  fail  to  obtain  relief  after  operations  and  treatment  simply 
because  the  intestinal  conditions  which  they  produce  have  not  been 
treated  at  the  same  time. 

The  interdependence  of  these  two  classes  of  diseases  requires  a  tech- 
nical knowledge  of  both  in  order  to  treat  either  one  successfully. 

Occupation:  Occupation  has  some  influence  in  the  production  of 
the  disease,  in  that  those  individuals  who  are  standing  upon  their  feet 
most  of  the  time,  whose  duties  require  them  to  lift  heavy  weights  and 
strain,  and  who  are  preoccupied  sufficiently  to  interfere  with  regular 
attention  to  the  functional  action  of  their  bowels,  are  liable  to  suffer 
from  constipation,  congestion,  and  other  conditions,  such  as  bring  about 
ulcers  of  the  rectum  and  sigmoid.  Painters,  workers  in  lead  and  phos- 
phorus, tailors,  seamstresses,  artists,  etc.,  are  all  frequent  subjects  of 
ulceration  of  the  rectum. 

Physiological  Functions. — The  functions  and  position  of  these  parts 
are  most  important  predisposing  causes.  Forming,  as  they  do,  the  final 
portion  of  the  intestinal  tract  and  serving  as  storehouses  for  the  harsh 
and  indigestible  refuse,  they  are  subject  to  continued  pressure  by  the 
mass,  and  to  abrasions  and  wounds  from  the  foreign  bodies  which  it  may 
contain.  Whenever  the  accumulation  of  faeces  remains  for  any  pro- 
tracted period  in  the  rectum  or  sigmoid  it  becomes  very  hard,  and  by  its 
constant  pressure  and  to-and-fro  movements,  caused  by  peristalsis  and 
respiration,  it  is  likely  to  produce  congestion,  abrasion,  or  even  actual 
wounds  of  the  mucous  membrane. 

Bacteria :  The  fact  that  there  are  always  present  in  the  intestinal 
canal,  especially  at  the  lower  end,  numerous  bacteria  and  bacilli,  predis- 


NON-SPECIFIC   tJLCERATlOXS  269 

poses  these  organs  to  ulceration  by  the  facility  with  which  any  injury 
of  the  parts  may  become  infected. 

Bacillus  coli  commune,  staphylococcus,  and  tubercle  bacillus  are 
more  or  less  constantly  found  here,  and  no  amount  of  attention  can 
keep  the  parts  free  from  exposure  to  infection  by  them.  In  other  cases 
peculiar  bacteria  are  found.  X.  Solojew  (Centralbl.  fiir  Bakteriologie, 
Parasitenkunde  und  Infektionskrankheiten,  1901,  I.  Abtheilung,  vol. 
xxix,  pp.  821-830)  has  reported  a  fatal  case  of  ulceration  of  the  colon 
and  rectum  due  to  the  balantidium  coli.  The  ulcers  were  extensive  and 
involved  the  entire  mucosa,  dipping  into  the  muscular  coat.  While 
various  micro-organisms  were  found  upon  the  surface,  only  this  peculiar 
parasite  penetrated  the  deeper  parts  of  the  ulcers.  He  therefore  con- 
siders it  the  etiological  factor. 

The  author  has  recently  seen  a  case  of  chronic  diarrhcea  with  ulcera- 
tion of  the  rectum  and  sigmoid  in  which  amoebge  dysenterise  were  found 
at  first,  and  later  on  numerous  trichomonas  intestinalis.  Thayer  (The 
Journal  of  Experimental  Medicine,  vol.  vi,  p.  75)  mentions  this  same  fact. 
He  also  calls  attention  to  the  presence  of  strongyloides  intestinalis  in  the 
colon  in  certain  cases  of  chronic  diarrhoea  with  intestinal  ulceration. 
The  etiological  influence  of  these  parasites  in  the  production  of  ulcera- 
tion has  not  yet  been  determined,  but  the  large  variety  of  such  agents 
found  in  the  alimentary  tract  makes  the  wonder  grow  that  we  do  not 
more  frequently  observe  infection  and  ulcerations  there. 

Anatomical  Causes. — The  distribution  of  the  superior  hsemorrhoidal 
veins,  the  fact  that  they  possess  no  valves,  and  that  the  collateral  circu- 
lation below  is  so  feeble,  predisposes  the  rectum  to  constant  congestion 
and  ulceration.  Especially  is  this  true  in  consequence  of  the  blood  pres- 
sure upon  these  parts  produced  by  the  erect  posture. 

Pathological  Predisposing  Causes. — Aside  from  the  specific  diseases, 
such  as  tuberculosis,  s}'philis,  dysentery,  etc.,  certain  other  constitutional 
and  organic  diseases  predispose  to  this  condition.  In  general,  one  may 
say  whatever  enfeebles  the  circulation  and  reduces  the  cardiac  force,  so 
that  it  does  not  move  the  blood  rapidly  through  the  portal  circulation, 
will  predispose  to  congestion  and  ulceration  of  the  rectum.  Valvular 
disease  of  the  right  side  of  the  heart,  hepatic  disorders,  and  atheroma  of 
the  arteries  all  contribute  to  this  disease. 

As  to  the  special  diseases  there  seems  to  be  some  lack  of  harmony 
among  writers  as  to  whether  they  simply  predispose  or  actually  occasion 
the  condition.  It  is  a  question  whether  Bright's  disease  has  any  pecul- 
iar influence  in  producing  ulcers  of  the  rectum  through  the  accumulation 
in  the  system  of  poisonous  detritus  which  should  be  eliminated  by  the 
kidneys ;  or  whether,  as  Da  Costa  has  brought  out,  in  the  later  stages 
of  this  disease  the  secretory  organs  of  the  body,  especially  the  liver,  the 


270  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

pancreas,  the  spleen,  and  the  heart  as  well,  all  take  on  more  or  less 
of  the  sclerotic  involvement  of  the  kidney,  and  thus  become  a  part  and 
parcel  of  the  disease,  the  rectal  ulcers  being  secondary  to  the  involve- 
ment of  these  organs,  and  not  due  to  the  chronic  inflammation  of  the 
kidneys  alone.  Of  course  in  those  cases  which  always  occur  in  the  late 
stages  of  Bright's  disease  there  is  feeble  cardiac  action,  general  vascular 
dilatation,  and  decreased  blood  pressure.  In  fact,  all  the  tissues  of  the 
body  are  in  a  degenerated  or  enfeebled  condition,  and  predisposed  to 
suffer  more  than  usual  from  slight  traumatisms,  as  well  as  being  easy 
victims  to  infection  by  septic  bacteria.  At  the  same  time,  as  we  shall  see 
later  on,  the  type  of  ulceration  seen  in  these  cases  is  entirely  different 
from  any  other  rectal  ulceration,  thus  lending  color  to  the  view  that  it  is 
due  to  Bright's  disease  itself. 

The  ulcers  of  the  rectum  that  are  caused  by  diabetes  are  similar  in 
their  nature  to  gangrene  of  other  portions  of  the  body  as  produced  by 
this  disease.  It  is  simply  a  gangrenous  or  necrotic  condition  of  the 
mucous  membrane  that  results  from  traumatisms  or  thrombotic  obstruc- 
tions in  the  venules,  and  may  occur  in  acute  as  well  as  chronic  cases  of 
this  disease.  The  author  has  seen  one  case  in  a  woman  whose  diabetes 
lasted  only  a  short  time,  and  yet  during  that  period  the  most  extensive 
ulcerations  of  the  rectum  and  sigmoid  occurred.  There  was  nothing  left 
of  the  mucous  membrane  of  these  two  organs  beyond  little  islands  or 
patches  about  the  size  of  a  silver  quarter,  as  high  up  as  the  longest 
sigmoidoscope  would  reach.  The  fact  that  the  ulceration  extended  after 
the  glycosuria  had  disappeared  is  in  keeping  with  other  reports  of  ulcer- 
ation of  the  skin  and  gangrene  of  the  extremities  that  occurred  after 
the  glycosuria  had  disappeared. 

Profound  ansemia  is  a  predisposing  cause  of  ulcers  of  the  rectum,  as  it 
is  of  ulcers  everywhere  else.  These  patients  are  generally  the  subjects  of 
obstinate  constipation,  the  stools  are  hard,  and  traumatism  from  this 
source  frequently  affords  an  open  gate  to  the  bacterial  infection  which 
results  in  the  ulcerative  process.  Neuroses  and  mental  diseases  have 
been  frequently  spoken  of  as  predisposing  causes  to  ulcers  of  the  rectum 
and  colon.  In  the  chapter  upon  mucous  and  ulcerative  colitis  attention 
has  been  called  to  the  fact  that  these  diseases  are  very  frequently  met 
with  in  institutions  for  the  nervous  and  the  insane.  Some  authors  have 
taken  the  view  that  it  is  the  result  of  trophic  changes,  while  others  be- 
lieve that  they  are  due  to  specific,  and  even  to  contagious  bacilli  (Cowan). 
On  the  other  hand,  lack  of  attention  to  the  calls  of  natvire,  want  of 
exercise,  and  altered  nervous  conditions,  such  as  reduce  peristalsis  and 
vascular  tension,  all  tend  to  produce  conditions  which  predispose  to 
ulceration  of  the  rectum  and  sigmoid.  Four  cases  of  ulceration  of  the 
rectum  and  one  of  the  sigmoid  have  been  observed  in  cases  of  non-syphi- 


NON-SPECIFIC  ULCERATIONS  271 

litic,  multiple  spinal  sclerosis;  in  one  case  even  an  artificial  anus  failed 
to  heal  the  ulcer.  It  appears,  therefore,  that  these  neuroses  may  be 
even  more  than  predisposing  causes  in  some  cases. 

Exciting  Causes. — Traumatism  or  injury  is  the  exciting  cause  of 
the  large  majority  of  non-specific  ulcerations  of  the  rectum.  These  may 
be  due  to  surgical  operations,  rough  introduction  of  syringe  tips,  the 
improper  use  of  bougies,  the  application  of  cauterizing  agents,  the  injec- 
tion of  corrosive  substances  in  the  treatment  of  haemorrhoids,  the  pas- 
sage of  hard  fsecal  masses,  the  introduction  into  the  anus  or  passage 
through  the  bowel  of  foreign  bodies,  and  the  rupture  of  hgemorrhoidal 
veins. 

N"ext  to  surgical  procedures  the  passage  of  foreign  bodies,  such  as 
bones,  pins,  fruit  seeds,  gall-stones,  etc.,  is  the  most  frequent  source  of 
ulcerations.  The  sharp  points  of  these  little  bodies  project  out  beyond 
the  fffical  mass  and  scratch  the  mucous  membrane,  thus  causing  small 
wounds,  which  soon  become  infected  and  cause  ulcerations. 

Pressure:  Prolonged  pressure  from  impacted  faeces,  from  arrest  of 
the  foetal  head,  from  pelvic  tumors,  and  from  too  large  pessaries,  may 
interfere  with  the  circulation,  cause  sloughing  of  the  mucous  membrane, 
and  thus  produce  ulceration  of  the  rectum. 

Crypts :  The  lodgment  of  foreign  bodies  or  small  masses  of  hard 
faeces  in  the  crypts  of  Morgagni  may  sometimes  cause  ulcerations  which 
extend  upward  and  involve  the  rectum. 

Drugs :  Finally,  the  toxic  action  of  certain  drugs  or  chemicals,  such 
as  mercury,  capsicum,  mustard,  phosphorus,  ergot,  and  carbonate  of 
ammonia,  have  been  known  to  cause  ulceration  of  the  rectum  and  pelvic 
colon. 

General  Symptoms.— HhQ  s}Tnptoms  of  ulceration  of  the  rectum  are 
very  similar  in  many  respects  for  all  varieties.  The  size  of  the  ulcer 
as  a  rule  bears  no  relationship  to  the  amount  of  disturbance  it  produces. 
Extensive  ulceration  well  above  the  internal  sphincter  may  cause  very 
slight  and  indefinite  symptoms,  whereas  a  very  small  ulcer  situated 
low  down  may  occasion  great  pain,  muscular  spasm,  nervous  irritability, 
and  reflex  disturbances  in  nearly  all  the  organs  of  the  body. 

Diarrhoea  is  one  of  the  early  symptoms  of  this  disease.  It  some- 
times comes  on  with  an  acute  attack  of  griping  and  pain  in  the  course 
of  the  colon.  Such  cases  are  due  to  colitis,  and  are  described  in  the 
chapter  upon  that  subject.  Frequently,  however,  it  occurs  as  a  gi-adu- 
ally  increasing  frequency  of  ftecal  movements.  At  first  these  will 
be  comparatively  normal  and  of  sufficient  amount.  They  will  grow 
smaller  as  the  desire  becomes  more  frequent,  and  instead  of  passing 
faecal  material  the  patient  will  have  frequent  calls  to  the  stool,  at  which 
nothing  more   than   a   small   quantity   of   mucus  will  be   discharged. 


272  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

Sometimes  this  mucus  is  tinged  with  bloody  at  others  there  may  be 
considerable  quantities  of  pure  blood  poured  out  along  with  pus.  Oc- 
casionally the  patient  will  pass  quantities  of  material  resembling  boiled 
sago.  Later  on  these  discharges  change  to  a  dark  and  grumous  material 
due  to  decomposed  blood  mixed  with  mucus,  ffeces,  and  pus.  The 
character  of  the  discharge  differs  considerably  in  the  various  types  of 
ulcerations,  as  will  be  described  under  their  appropriate  headings. 

Morning  Diarrhoea. — One  peculiar  characteristic  of  the  diarrhoea  in 
ulceration  of  the  rectum  is  that  it  is  generally  quiescent  at  night, 
whereas  in  the  da}i:ime  the  patient  suffers  from  frequent  calls  to  stool. 
He  may  have  eight  to  ten  or  more  passages  during  the  day,  and  yet 
go  to  bed  and  sleep  all  night  without  any  disturbance.  Upon  rising 
in  the  morning,  however,  he  will  be  called  upon  at  once  to  relieve 
the  bowels. 

Delafield  (Medical  Eecord,  1895,  vol.  i,  p.  577)  states  that  this  morn- 
ing diarrhoea  is  a  constitutional  or  neurotic  condition  not  due  to  local 
inflammation  or  disease,  and  describes  five  varieties,  according  to  the 
severity  of  the  symptoms,  but  leaves  one  to  infer  that  there  is  no 
organic  disease  of  the  intestinal  tract  to  account  for  them. 

With  such  an  opinion  every  close  observer  in  rectal  diseases  will 
take  most  positive  issue.  True  morning  diarrhoea,  such  as  he  has  de- 
scribed in  his  last  four  divisions,  is  pathognomonic  evidence  of  local 
inflammation,  stricture,  ulceration,  or  neoplasm  of  the  rectum,  sigmoid, 
or  colon.  There  is  no  condition  that  more  positively  demands  an 
early  and  thorough  examination  of  the  rectum  and  sigmoid  flexure 
than  this  tendency  to  go  to  stool  immediately  upon  rising  in  the  morn- 
ing, especially  if  that  morning  stool  consists  in  mucus  or  purulent  dis- 
charges. There  are  persons  who  have  a  normal  call  to  defecate  as 
soon  as  they  rise,  or  shortly  after  rising,  in  the  morning;  the  passages 
are  normal  and  there  is  no  continuous  call  throughout  the  day  in  such 
cases.  But  these  are  an  entirely  different  class  from  those  described 
by  the  author  mentioned  and  which  are  discussed  here.  The  morning 
diarrhoea,  which  consists  in  the  passage  of  mucus  or  pus,  is  due  in 
almost  every  instance  to  ulcerative  disease  of  the  rectum  or  sigmoid. 

Pain. — This  is  a  very  unreliable  and  indefinite  symptom  in  ulcera- 
tion of  the  rectum.  Certain  individuals  suffer  greatly  from  it,  while 
others  have  no  pain  at  all.  If  the  ulceration  is  high  up  in  the  rec- 
tum a  sense  of  weight  and  aching  in  the  sacral  region  is  the  chief 
discomfort  of  which  most  patients  complain.  If  it  is  situated  lower 
down  within  the  grasp  of  the  sphincter,  and  involves  the  muco-cutane- 
ous  area  where  the  sensitive  nerve-ends  center,  pain  of  a  sharp,  lancinat- 
ing, or  burning  character  will  be  the  chief  symptom. 

The  amount  of  pain  varies  considerably  with  the  character  of  the 


NON-SPECIFIC   ULCERATIONS  273 

ulceration.  Tubercular  ulcers  are  almost  entirely  free  from  it.  Syphi- 
litic ulcers  vary  considerably  in  this  regard;  sometimes  they  are  very 
sensitive,  at  others  the  patient  is  almost  absolutely  without  any  pain, 
but  this  depends  ujjon  the  location.  As  a  rule  ulceration  of  the  rectum 
proper  is  not  an  acutely  painful  affection. 

Incontinence. — Relaxation  of  the  sphincter  is  not  an  infrequent 
symptom  of  ulceration  of  the  rectum.  Sometimes  patients  almost  en- 
tirely lose  control  over  their  faecal  passages  owing  to  this  condition.  It 
does  not  occur,  however,  except  where  the  disease  has  existed  for  a 
long  time  or  has  been  brought  about  either  by  serious  constitutional 
diseases  or  vicious  practices. 

The  symptoms  elicited  by  sight  and  touch  vary  with  each  particular 
class  of  ulcers.  These  variations  when  within  reach  can  be  appreciated 
by  the  educated  touch,  but  the  various  instrumental  aids  for  ocular 
examination  of  the  rectum  enable  us  at  the  present  day  to  distinguish 
between  the  different  ulcers  much  more  clearly  than  before.  Through 
the  pneumatic  proctoscope  one  can  clearly  see  and  diagnose  ulcera- 
tions in  the  upper  portions  of  the  rectum  and  in  the  sigmoid;  the 
character  of  the  ulcers  can  be  determined  and  the  amount  of  contrac- 
tion in  the  caliber  of  the  gut  can  be  accurately  measured  without  any 
danger  of  perforation.  The  appearance  of  special  ulcerations  will  be 
described  under  their  proper  headings. 


SPECIAL    ULCERATIONS 

Traumatic  Ulceration  of  the  Rectum. — This  form,  termed  also 
simple  ulceration  of  the  rectum,  always  originates  in  some  injury  to 
the  parts.  The  ulcerative  condition  is  due  to  infection  of  the  raw 
surfaces  by  the  bacteria  always  present  in  the  rectum.  This  distin- 
guishes them  from  those  ulcerations  which  are  due  to  specific  bacilli, 
such  as  tuberculosis,  typhoid  fever,  dysentery,  etc. 

Ulcerations  following  surgical  operations,  when  in  patients  other- 
wise healthy,  tend  toward  spontaneous  healing,  but  they  may  some- 
times be  protracted  on  account  of  the  irritation  caused  by  the  passage 
of  hard  f^cal  masses  and  the  impossibility  to  keep  them  clean. 

The  lower  the  seat  of  an  ulceration  in  the  rectum,  provided  the 
sphincter  is  kept  relaxed,  the  more  rapidly  will  it  heal,  because  the 
fsecal  materials  do  not  rest  so  persistently  upon  the  parts  and  cleanli- 
ness is  rendered  more  possible.  Thus  in  open  operations  for  hsemor- 
rhoids  or  fistulas  the  tendency  is  always  for  the  lower  portion  of  the 
wound  to  cicatrize  before  the  upper  portion.  Another  thing  which 
must  always  be  taken  into  consideration  with  regard  to  these  traumatic 
ulcers  is  the  trophic  condition  of  the  parts.  Whenever  an  ulceration 
18 


274  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

in  the  rectum  shows  a  tendency  to  chronicity  it  is  evidence  that  the 
resisting  power  of  the  tissues  is  not  sufficient  to  overcome  the  constant 
infection  from  the  intestinal  contents.  The  circulation  is  either  im- 
perfect, the  nerve  supply  is  impaired,  or  the  general  reparatory  pro- 
cesses are  below  par.  Constitutional  treatment,  therefore,  becomes  a 
necessary  feature  in  the  management  of  these  cases. 

Characteristics. — The  appearance  of  such  ulcers  is  largely  the  conse- 
quence of  the  injury  or  wound  in  which  they  originate.  If  these  involve 
only  the  mucous  membrane  the  ulcers  will  be  superficial  and  assume 
the  form  of  the  original  lesion.  If,  however,  the  operation  or  injury 
involves  the  deeper  tissues  of  the  gut  wall  they  will  then  assume  the 
penetrating  form,  and,  if  not  properly  treated,  may  burrow  into  the 
perirectal  tissues  and  form  an  abscess  or  fistula.  "VTlien  upon  the  an- 
terior wall  of  the  gut  they  may  even  perforate  the  peritonaeum  or 
the  vagina. 

The  edges  of  the  ulcers  are  generally  smooth,  sloping,  and  non- 
indurated.  The  bases  are  composed  of  simple  granulations,  neither 
nodular  nor  proliferating,  bathed  in  a  thick,  milky-white  secretion  con- 
taining pus-cells,  streptococci,  colon  bacilli,  and  the  other  bacteria 
usually  present  in  the  rectum. 

When  the  ulceration  extends  low  down  in  the  rectum,  involving 
the  anal  canal,  it  may  assume  the  form  of  a  fissure  in  ano.  However, 
ulcerations  resulting  from  surgical  operations  very  rarely  present  the 
symptoms  of  this  condition  owing  to  the  fact  that  the  sphincter  is  gen- 
erally well  stretched  as  a  preliminary  step. 

Symptoms. — The  symptoms  of  traumatic  ulcers  are  practically  de- 
scribed in  the  foregoing  paragraph  on  general  s^^mptoms.  They  pos- 
sess no  peculiarities  beyond  that  of  chronicit}",  and  frequently  this 
tendency  is  onl}^  comparative.  Ulcerations  following  operations  for 
haemorrhoids  should  not  be  expected  to  heal  under  three  to  four  weeks, 
and  they  may  require  five  or  six,  while  those  produced  by  operations 
for  fistula  and  stricture  sometimes  require  three  to  six  months  in  which 
to  heal.  The  constitutional  condition  of  the  patient  has  much  to  do 
with  this.  The  fact  that  an  operation  or  an  accidental  wound  of  the 
rectum  or  anus  is  slow  in  healing  should  not  lead  one  to"  conclude  that 
it  is  tubercular,  syphilitic,  or  malignant  without  much  stronger  evi- 
dence. Assuming  the  erect  posture  too  soon,  too  little  and  improper 
attention  to  dressings  and  cleanliness,  anaemia,  poor  circulation,  and 
feeble  reparative  powers  may  all  bring  about  tardiness  of  healing  in  a 
perfectly  healthy  wound. 

Treatment. — The  treatment  of  this  tj^ie  of  ulcers  consists  in  perfect 
drainage,  aseptic  cleanliness,  regulation  of  the  bowels,  and  rest  in  the 
recumbent  posture.    If  the  sphincter  is  not  relaxed  it  should  be  dilated. 


NON-SPECIFIC  ULCERATIONS  275 

The  parts  should  be  irrigated  with  antiseptic  solutions  two  or  three 
times  a  day,  and  applications  of  astringent  solutions,  such  as  nitrate  of 
silver,  ichthyol,  or  Peruvian  balsam  should  be  made. 

Powders,  such  as  have  been  mentioned  under  specific  ulcerations,  will 
be  useful  after  the  discharge  is  practically  controlled.  Iodoform  is 
one  of  the  best  in  this  condition. 

Catarrhal  TJlceration. — In  the  chapter  upon  catarrhal  diseases  of  the 
rectum  it  was  stated  that  ulceration  may  result  from  any  one  of  the 
three  varieties — the  acute,  hypertrophic,  or  atrophic  catarrh. 

The  ulcerations  that  result  from  acute  catarrhal  inflammation  of 
the  intestine  are  due  to  excessive  inflammatory  processes,  followed  by 
necrosis  of  the  mucous  membrane  and  consequent  sloughing.  This 
ulceration  is  a  superficial  condition,  and  is  generally  quite  exten- 
sive, involving  more  or  less  of  the  entire  lining  membrane  of  the 
rectum.  The  symptoms  are  those  of  an  acute  inflammatory  disease,  fol- 
lowed by  a  frequent  desire  to  defecate  and  the  passage  of  blood  and  pus. 
The  mucous  membrane  around  the  margin  of  the  anus  is  generally 
inflamed,  and  oedematoiis,  if  it  is  not  also  involved  in  the  ulcer- 
ative process.  The  patient  suffers  from  acute  pains  upon  defecation, 
aching  and  discomfort  in  the  sacral  region,  and  always  has  more  or 
less  temperature  at  different  times  of  the  day,  especially  in  the 
evening. 

Ulcerations  from  the  hypertrophic  form  of  catarrh  are  very  rare. 
They  are  more  likely  to  assume  the  follicular  type  and  be  localized  in 
the  solitary  follicles  or  lymphoid  glands.  They  do  not  produce  any 
marked  subjective  symptoms,  they  rarely  bleed,  and  discharge  a  thin 
sero-purulent  material  which  is  not  feculent  but  quite  irritating  to  the 
muco-cutaneous  membrane. 

The  ulceration  caused  by  atrophic  catarrh  is  generally  more  of  an 
erosion  than  an  ulceration.  It  consists  in  a  localized  breaking  down 
of  the  mucous  membrane.  The  edges  are  not  elevated  or  swollen,  but 
gradually  decline  to  a  shallow  crater-like  base.  They  bleed  easily  upon 
touch,  though  not  excessively.  They  discharge  a  thick  tenacious  muco- 
pus  which  can  be  seen  adhering  to  the  spots  when  examination  is  made 
by  the  speculum  (Plate  I,  Fig.  6).  This  muco-pus  often  contains  small 
bits  of  inspissated  fgecal  matter  which  gives  the  discharge  a  dark-brown- 
ish color  at  times.  Owing  to  the  scarcity  of  the  discharge  diarrhoea  is 
not  a  frequent  symptom  in  this  form  of  ulceration. 

The  minute  description  and  treatment  of  these  varieties  of  ulcera- 
tions has  been  given  in  the  chapter  upon  catarrhal  diseases  and  need 
not  be  repeated  here. 

Varicose  Ulceration. — Under  the  above  term  many  writers  have  con- 
fused two  separate  and  distinct  varieties  of  ulceration.     Eokitansky 


276  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

(Manual  of  Path.  Anat.,  aoI.  ii,  p.  10?)  described  under  the  name  of 
"  hEemorrhoidal  ulcers  "  a  condition  which  Gibbs,  Kelse}-,  Curling,  and 
others  have  called  varicose  ulcers  of  the  rectum.  It  is  necessary  for  the 
proper  understanding  of  this  subject  to  clearly  distinguish  between  an 
ulceration  due  to  a  varicose  condition  of  the  rectal  mucous  membrane 
and  those  due  to  injury,  strangulation,  or  sloughing  of  haemorrhoidal 
tumors.  An  ulcerated  hgemorrhoid  or  an  ulcer  that  occurs  in  a  well- 
developed  lia?morrhoid  is  an  entirely  different  condition  from  those 
chronic,  intractable  ulcers  which  occur  in  general  varicosity  of  the  rectal 
mucous  membrane. 

The  lamented  Gibbs,  whose  tragic  death  was  the  first  fatality  in  our 
late  war  with  Spain,  has  clearly  drawn  this  distinction  (Xew  York  Med- 
ical Journal,  1892,  vol.  ii,  p.  93).  Ball  describes  the  same  condition, 
but  unfortunately  adopts  the  nomenclature  of  Rokitansky,  who  first 
likened  it  to  chronic  varicose  ulcers  of  the  leg.  The  conditions  are 
almost  identical,  but  if  one  examines  these  ulcers  in  the  rectum  he  will 
find  no  hyperplasia  or  fibrous  thickening  beneath  them,  such  as  is  seen 
in  varicose  ulcers  of  the  leg.  They  show  no  tendency  to  cicatrize,  as  do 
the  latter  type,  and  bleed  much  more  easily,  owing  to  the  thin  vascular 
walls  of  this  area. 

Again,  the  so-called  varicose  ulcers  of  the  leg  are  associated  in  the 
majority  of  cases  with  chronic  syphilis;  those  in  the  rectum  are  not. 
Their  chronicity  is  undoubtedly  due  to  varicosities  of  the  superior 
hjemorrhoidal  veins.  The  original  exciting  cause,  however,  is  unques- 
tionably some  wound  or  injury  to  the  mucous  membrane,  or  rupture 
of  one  of  the  varicose  veins.  Infection  takes  place  after  this  and  causes 
the  ulceration.  "\Miatever  tends  to  produce  varicosity  of  the  rectal  veins 
is  a  predisposing  cause  to  the  condition. 

Cripps  (op  cit.,  p.  206),  Quenu  and  Hartmann  (op.  cit.,  p.  413)  state 
that  these  ulcers  are  peculiar  to  old  age.  In  the  series  of  cases  described 
by  Gibbs  there  was  a  number  under  the  age  of  twenty  years,  and  the 
majority  of  them  occurred  in  people  between  twent)'  and  fifty  years  of 
age.  The  author  has  seen  this  character  of  ulceration  in  a  patient  as 
young  as  seventeen  years,  and  in  the  large  number  of  old  people  in  the 
Xew  York  Almshouse  he  has  only  seen  three  of  these  ulcerations  in 
patients  above  the  age  of  sixty,  whereas  in  his  clinical  and  hospital 
services  he  has  seen  a  large  number  that  occurred  in  patients  between 
thirty  and  fifty  years  of  age. 

Mode  of  life,  environment,  and  nutrition  seem  to  have  very  little 
influence  in  its  production.  Heavy  eaters  and  drinkers  who  take  little 
exercise  and  are  inclined  to  constipation  are  predisposed  to  this  type 
of  ulceration,  but  it  also  occurs  in  abstemious,  active,  and  anaemic  indi- 
viduals.   The  etiological  factors  in  one  type  of  eases  are  congestion  of 


NON-SPECIFIC  ULCERATIONS  277 

the  liver  and  constipation;  and  in  the  other  feeble  cardiac  action  and 
weak  relaxed  blood-vessel  walls. 

Symptoms. — The  ulcers  usually  occur  well  above  the  muco-cutaneous 
border.  As  a  rule,  they  produce  very  few  symptoms  besides  the  frequent 
desire  to  defecate.  This  inclination  is  always  more  marked  in  the  day- 
time, the  patient  often  passing  the  whole  night  without  being  disturbed. 
There  is  always  an  inclination  to  go  to  stool  immediately  upon  rising  in 
the  morning,  which  generally  results  in  the  passage  of  small  quanti- 
ties of  mucus  and  pus,  with  or  without  blood.  Occasionally  these  pa- 
tients suffer  from  quite  severe  haemorrhages.  One  or  two  cases  have 
been  reported  in  which  death  was  caused  by  this  accident,  but  ordinarily 
bleeding  is  not  a  marked  characteristic. 

Pain,  other  than  a  dull  aching  in  the  back,  sometimes  shooting 
down  the  leg  or  around  the  pelvis,  is  generally  absent,  as  might  be 
expected  from  the  location  of  the  ulcer  above  the  muco-cutaneous  bor- 
der. Occasionally  when  they  invade  the  muco-cutaneous  tissue  at  the 
margin  of  the  anus  the  patient  suffers  from  more  or  less  acute  pain. 
In  this  condition  spasm  of  the  sphincter  will  also  complicate  the 
ulceration. 

The  appearance  of  the  ulcers  upon  ocular  examination  is  that  of  a 
sharply  defined,  irregular  depression  in  the  mucous  membrane  of  the 
rectum.  The  edges  are  slightly  elevated,  and  the  bases  covered  with  a 
yellowish  pus,  beneath  which  there  are  bright-red  granulations.  The 
veins  of  the  rectum  surrounding  the  ulcerated  portion,  and,  in  general, 
all  over  the  rectum,  are  varicose,  and  when  the  patient  strains  they  be- 
come largely  dilated.  The  patient  may  or  may  not  have  well-developed 
hemorrhoidal  tumors.  When  such  is  the  case  the  ulceration  occurs  at 
the  side  of  or  between  two  such  masses.  Ordinarily  these  ulcerations  are 
superficial,  but,  as  Gibbs  states,  they  sometimes  eventuate  in  great  de- 
struction of  tissue,  even  perforation  of  the  bowel. 

One  striking  characteristic  is  their  extreme  chronicity,  with  little 
or  no  tendency  to  extend  either  in  area  or  depth ;  one  case  was  seen  in 
which  the  condition  existed  for  five  or  six  years,  the  ulcer  remaining 
about  the  size  of  a  twenty-five-cent  piece,  and  with  absolutely  no  con- 
traction of  the  caliber  of  the  gut. 

Tenesmus  and  griping  are  ordinarily  absent. 

The  condition  of  the  bowels  will  depend  upon  other  circumstances; 
when  they  are  soft  and  semifluid,. bleeding  and  pain  will  be  generally 
absent;  when  they  are  hard,  lumpy,  and  irregular,  a  small  amount  of 
blood  will  appear  with  and  after  the  stools,  and  a  dull  aching  pain  may 
follow  and  last  for  an  hour  or  two. 

Dig-ital  examination  reveals  nothing  more  than  a  lesion  of  the  mu- 
cous  membrane,  with  slightly  elevated  edges,  and  a  soft  elastic  base. 


278  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

There  is  little  if  any  hyperplasia  or  thickening  of  the  intestinal  walls 
about  or  beneath  these  ulcers. 

Treatment. — The  treatment  of  varicose  ulcers  of  the  rectum  is 
very  tedious  and  frequently  unsatisfactor}\  It  is  very  difficult  to  get 
patients  to  appreciate  the  importance  of  a  condition  which  gives  them 
so  little  real  pain  or  inconvenience.  At  the  same  time  it  is  almost  im- 
possible to  heal  these  conditions  without  absolute  rest  in  bed.  They 
insist  upon  sitting  up,  if  they  yield  at  all  to  the  advice  of  confinement. 
They  want  to  be  propped  up  in  bed,  clothe  themselves,  and  lounge  about 
the  room  in  chairs  or  upon  sofas,  or  even  want  to  attend  to  business  a 
few  hours  each  day.  In  chronic  cases,  with  general  varicosity  of  the 
rectum,  such  lax  regimen  will  rarely  succeed.  The  patient  should  be 
confined  absolutely  in  a  reclining  posture.  He  may  lie  upon  his  side, 
his  back,  or  his  stomach  if  he  wishes,  but  his  head  should  be  on  a  level 
with  or  as  little  elevated  above  his  hips  as  possible.  The  modern  treat- 
ment of  varicose  ulcers  of  the  leg  by  the  elevation  of  the  limb  has  proved 
beyond  a  doubt  the  benefit  of  removing  the  pressure  of  the  blood  column 
in  these  conditions.  So  also  in  the  rectum,  in  which  this  column  is  even 
more  unsupported  than  in  the  leg,  there  being  no  valves  in  the  veins,  it 
is  necessary  to  relieve  the  parts  of  that  mechanical  element  of  conges- 
tion in  order  to  bring  about  the  healthy  circulation  and  consequent  res- 
toration of  tissue  which  has  been  destroyed.  If  this  were  conscientiously 
enforced,  it  is  believed  that  the  majority  of  cases  of  simple  and  varicose 
ulceration  would  heal  of  their  own  accord.  Xevertheless  something  may 
be  done  toward  hastening  such  a  cure. 

The  diet  should  be  regulated  so  as  to  contain  as  little  refuse  material 
as  possible.  An  absolute  milk  diet  is  not  best  for  these  patients,  as  it 
produces  a  hard,  leathery  stool,  which,  when  passed  through  the  rectum, 
tears  and  irritates  the  already  inflamed  surfaces.  An  albuminoid  diet 
associated  with  a  reasonable  amount  of  fresh  garden  vegetables  is  more 
acceptable  as  well  as  more  effectual.  A  certain  amount  of  milk  may  be 
allowed  with  this  diet,  as  it  is  nourishing  and  produces  no  bad  effects 
in  combination  with  the  other  food.  Alcohol,  and  if  possible  tea  and 
coffee,  should  be  avoided,  also  all  such  condiments  as  mustard,  pepper, 
and  the  various  sauces. 

The  bowels  should  be  kept  regular  but  not  loose.  After  the  bowels 
have  moved,  and  at  least  twice  a  day,  the  rectum  should  be  irrigated 
with  a  cleansing  solution,  either  of  bichloride  of  mercury  (1  to  10,000), 
boric  acid,  or  Thiersch's  solution,  the  ordinary  rectal  irrigator  being 
used  for  this  purpose.  By  this  means  no  accumulation  of  fluid  will  be 
left  in  the  rectum  to  irritate  the  parts  and  cause  a  tendency  to  defecate. 

As  local  applications  to  these  ulcerations  a  variety  of  substances  are 
useful.    Most  authors  advise  nitrate  of  silver  in  mild  solutions.     Occa- 


NON-SPECIFIC   ULCERATIONS  279 

sionally,  where  the  ulcer  is  sluggish  and  the  base  is  sloughing,  the  appli- 
cation of  this  agent  may  be  of  benefit.  My  own  experience,  however, 
has  been  that  tincture  of  iodine  or  a  10-per-cent  solution  of  argonin 
acts  better.  The  insufflation  of  a  powder  of  iodoform,  aristol,  or,  better 
still,  antinosin  upon  these  ulcerations  seems  to  hasten  their  healing, 
and  also  gives  the  patient  the  impression  that  something  is  actually 
being  done  to  heal  the  parts  while  he  is  resting  in  bed.  This  should  be 
done  once  or  twice  daily  through  a  fenestrated  or  duck-bill  speculum. 
If  the  pain  is  severe  a  suppository  of  iodoform,  opium,  and  belladonna 
may  be  introduced  two  or  three  times  a  day  to  relieve  the  same.  As  to 
giving  any  definite  quantities  of  these  drugs,  it  is  impossible  to  judge 
what  will  relieve  one  patient  by  any  experience  with  another.  Some 
are  very  susceptible  to  opium,  others  to  belladonna,  and  still  others 
to  iodoform,  and  the  proportion  must  be  varied  in  each  individual 
case. 

Injections  of  starch-water  or  of  flaxseed  tea  containing  small  quan- 
tities of  the  tincture  of  opium,  or  ointments  containing  small  quanti- 
ties of  cocaine,  may  be  of  benefit,  especially  if  the  ulcers  are  so  low  down 
in  the  rectum  as  to  involve  the  sensory  nerves.  In  the  majority  of  cases, 
however,  the  symptoms  will  not  indicate  the  use  of  analgesics.  Four  to 
ten  weeks  or  <more  may  be  consumed  in  healing. 

Drugs,  such  as  hypophosphites,  cod-liver  oil,  protonuclein,  and 
sometimes  some  assimilable  form  of  iron,  should  be  used  in  cases  asso- 
ciated with  anaemia  and  general  debility.  Where  signs  of  improvement 
do  not  manifest  themselves  very  soon,  it  is  wise  to  eliminate  all  possibil- 
ity of  syphilis  by  beginning  mercuric  inunctions. 

Massage  is  useful  in  all  patients  confined  to  bed,  and  makes  up  in 
a  measure  for  the  lack  of  exercise.  Forced  feeding,  such  as  is  employed 
in  neurasthenia,  should  be  avoided  in  these  cases.  The  danger  is  in 
overeating  and  congestion  of  the  portal  circulation.  Sufficient  whole- 
some food  should  be  allowed,  but  the  digestive  organs  should  not  be 
overtaxed.  Water  may  be  allowed  in  abundance,  especially  if  taken  hot, 
and  when  there  is  any  uricgemic  tendency,  citrate  of  lithia  may  be  added 
to  it. 

Haemorrhoidal  Ulcers. — In  distinction  to  the  above  variety  there  is 
the  lesion  caused  by  sloughing  and  ulceration  of  a  well-defined  hemor- 
rhoidal mass.  This  may  be  due  to  thrombosis  followed  by  necrosis,  trau- 
matism from  the  passage  of  hard  faecal  masses  or  foreign  bodies,  strangu- 
lation, or  too  rough  handling  of  the  tumor  in  efforts  to  reduce  it.  It 
may  also  be  produced  by  the  application  of  ice  in  order  to  relieve  con- 
gestion, and  by  the  action  of  corrosive  substances  applied  to  the  surface 
or  injected  into  the  body  of  the  hsemorrhoid  for  the  purpose  of  cur- 
ing it. 


280  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

Such  ulcerations  are  entirely  distinct  from  the  varicose  ulcerations 
which  have  just  been  described.  They  are  associated  with  a  localized 
inflammatory  condition;  the  hsemorrhoidal  tumor  itself  is  swollen  and 
hard;  the  ulceration  usually  consists  in  a  fissure-like  crack  or  split 
through  its  center,  or  in  a  protruding  stump  from  which  the  hemorrhoid 
has  sloughed  away.  Where  it  is  due  to  thrombosis,  traumatism,  or  cor- 
rosive injections,  it  generally  assumes  the  fissure-like  appearance  in  the 
body  of  the  tumor.  Where  it  is  due  to  necrosis  following  strangulation, 
the  application  of  ice,  or  cauterization,  the  summit  of  the  tumor  will 
slough  off  and  leave  an  ulcerating,  teat-like  stump.  These  ulcers  do  not 
possess  the  extreme  chronicity  of  the  varicose  variety — in  fact,  they  have 
a  tendency  to  heal  spontaneously. 

Symptoms. — The  symptoms  of  this  variety  of  ulceration  are  :  First,  a 
history  of  the  existence  of  hasmorrhoids  either  internal  or  external,  and 
of  prolapse,  strangulation,  efforts  at  reduction,  the  application  of  ice  or 
cauterizing  agents  for  the  restoration  or  removal  of  the  tumors.  After 
these  conditions  a  fulness,  throbbing,  and  aching  of  the  parts  will 
have  been  experienced  by  the  patient.  Sometimes  he  will  have  suf- 
fered from  a  chill  and  elevation  of  temperature.  These  symptoms  will 
have  been  suddenly  relieved  by  the  discharge  of  pus  or  blood.  Then 
follows  an  inclination  to  frequent  movements  of  the  bowels,  which  are 
generally  ineffectual,  and  associated  with  considerable  pain.  The 
discharge  is  scanty  and  composed  of  pus  and  blood.  Serious  haemor- 
rhages sometimes  occur;  there  is  always  more  or  less  spasm  of  the 
sphincter,  and  the  pain  is  more  marked  than  in  the  varicose  variety. 
Where  the  hcemorrhoid  is  only  partly  destroyed  it  may  prolapse,  and 
being  grasped  by  the  sphincter,  cause  acute  suffering. 

Morning  diarrhoea  may  or  may  not  be  present,  but  the  patient  is 
frequently  awakened  at  night  by  the  spasmodic  contraction  of  the 
sphincter  and  the  desire  to  defecate.  If  the  hemorrhoid  is  of  the  ex- 
ternal or  mixed  variety  the  involvement  of  the  muco-cutaneous  border 
may  take  place,  and  when  such  is  the  case  the  symptoms  of  fissure  de- 
velop. 

Treatment. — The  treatment  of  this  form  is  entirely  different  from 
that  of  varicose  ulceration.  It  is  absolutely  and  unequivocally  surgi- 
cal. The  patient  should  be  etherized,  the  sphincter  thoroughly  dilated, 
and  the  ulcerated  haemorrhoidal  mass  taken  away  either  by  crushing, 
the  clamp  and  cautery,  or  by  ligation. 

The  clamp-and-cautery  operation  by  its  stimulating  effect  and  bac- 
tericidal action  seems  to  be  as  near  a  specific  as  one  can  desire.  Where 
the  ulcerated  hemorrhoid  is  cleft  in  two  by  a  deep  furrow,  each  late'i-al 
prominence  should  be  clamped  separately  and  the  ulcerating  sulcus  be- 
tween them  cauterized  with  a  narrow-pointed  Paquelin  blade,  but  if 


NON-SPECIFIC  ULCERATIONS 


281 


the  furrow  does  not  dip  down  deep,  the  whole  mass  may  be  included  in 
the  clamp  and  removed. 

The  after-treatment  of  such  cases  is  identical  with  that  for  ordi- 
nary hsemorrhoidal  operations,  with  this  exception:  that  more  prolonged 
rest  in  bed,  antiseptic  washes,  and  restricted  diet  will  be  necessary  to 
obtain  perfect  results. 

Follicular  Ulceration  of  the  Rectum. — Follicular  ulceration  may  oc- 
cur at  any  portion  of  the  large  intestine.  Its  most  frequent  site  is  in 
the  descending  colon,  sigmoid,  and  rectum.  It  has  its  origin  in  the 
accumulation  of  small  round  cells  in  solitary  follicles.  This  accumula- 
tion causes  a  swelling  of  the  follicle  followed  by  pressure  on  the  epi- 
thelial covering,  which  finally  gives  way.  The  follicle  disintegrates,  and 
an  ulcer  results  having  sharply  cut  edges,  slightly  undermined,  and  vary- 
ing in  depth  (Plate  I,  Fig.  5).  They  vary  in  size  from  that  of  a  small 
bird-shot  to  a  small  hazelnut.  They  may  be  single  or  multiple,  the 
whole  mucous  mem- 
brane being  studded 
with  them;  they  are 
more  frequent  above 
the  r  e  c  t  o  -  sigmoidal 
juncture  than  below 
it;  they  do  not  often 
coalesce,  but  occasion- 
ally the  mucous  mem- 
brane between  two  may 
break  down,  and  thus 
form  an  irregular  ulcer. 

White  states  that  all  the  patients  in  whom  this  has  been  found  post 
mortem  have  died  from  other  causes,  such  as  dysentery,  typhoid  fever, 
tuberculosis,  cancer,  or  membranous  colitis.  lie  states  further  that  the 
disease  occurs  about  once  in  500  post-morten  examinations  at  Guy's 
Hospital,  and  yet  with  this  important  percentage  he  says  that  it  is  never 
diagnosed  during  life.  This  latter  opinion  is  not  in  accordance  with 
that  of  other  observers.  The  author  has  certainly  seen  the  condition 
in  the  rectum  and  sigmoid  flexure  of  living  subjects  a  number  of  times. 
In  the  majority  of  cases  catarrhal  disease  precedes  its  development.  That 
perforation  may  occur  from  this  form  of  ulceration  is  exemplified  in  Fig. 
100,  illustrating  the  cavity  of  such  an  ulcer  filled  with  fgeces.  It  will  be 
seen  that  only  the  peritoneum  itself  separates  it  from  the  abdominal 
cavity.  In  this  case  numerous  follicular  ulcerations  of  the  sigmoid  had 
involved  and  almost  perforated  the  intestinal  wall.  Healing  occurs  slow- 
ly, but  is  not  accompanied  by  the  development  of  any  marked  cicatricial 
deposit.     Ball  (loc.  cit.,  p.  119)  states  that  this  condition  may  result 


Fig.  100.- 


-Impacted  FiECEs  IN  Cavity  of  a  Follicular 
UlcePw. 


282  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

in  stenosis  of  the  bowel,  but  the  writer  has  never  seen  a  case  of  this 
kind. 

Symptoms. — The  s3-mptoms  of  this  form  of  ulceration  are  very 
meager.  In  the  rectum  itself  the  patient  experiences  no  pain  and  no 
uneasiness.  There  is  some  indication  of  intestinal  indigestion  associ- 
ated with  more  or  less  griping  and  tenesmus,  but  without  any  real  diar- 
rhoea. 

The  action  of  the  bowels  may  be  perfectly  normal  so  far  as 
the  constituency  of  the  mass  is  concerned,  but  the  patient  will  com- 
plain of  more  or  less  acute  griping  pains  throughout  the  day  and 
night. 

Bamburger  has  described  little  masses  of  inspissated  mucus,  looking 
something  like  frogs'  spawn  or  boiled  sago,  as  having  been  discharged 
from  the  bowels  of  patients  suffering  with  this  condition.  The  little 
masses  are  said  to  be  more  or  less  of  the  nature  of  follicles,  but  Vir- 
chow  has  shown  them  to  be  particles  of  undigested  starch,  and  there- 
fore it  is  doubtful  if  they  have  any  real  relationship  to  follicular  ulcer- 
ation. In  the  early  stages,  before  ulceration  takes  place,  one  may  occa- 
sionally feel  little  millet-seed-like  formations  beneath  the  mucous  mem- 
brane, or  elevations  upon  its  surface,  but  it  requires  a  delicate  touch  to 
do  this.  Examination  with  the  speculum,  which  is  the  only  positive 
means  of  diagnosis,  shows  in  this  stage  very  slight  elevations,  over  which 
the  membrane  appears  smooth  and  shining. 

The  causes  of  this  variety  of  ulceration  are  practically  unknown,  but 
insomuch  as  it  always  occurs  in  connection  with  some  other  inflammatory 
affection  of  the  rectum,  it  seems  rational  to  regard  it  as  an  infection  of 
the  follicles  by  the  discharge  from  these  diseases. 

Treatment. — The  treatment  consists  in  attacking  the  causative  dis- 
ease and  applying  local  remedies  to  the  ulcers  so  far  as  they  can  be 
reached.  In  the  case  illustrated  the  patient  was  suffering  from  atrophic 
catarrh  of  the  rectum  and  sigmoid.  The  treatment  consisted  in  that 
detailed  in  the  chapter  upon  this  disease,  and  the  four  or  five  ulcers 
which  could  be  reached  were  treated  by  wiping  them  out  with  small 
pledgets  of  cotton  and  insufflating  antinosin  upon  the  ulcerated  spots. 
The  patient  recovered  in  about  six  weeks,  and  has  not  been  troubled 
with  the  condition  since. 

Strictural  Ulceration. — Cripps  {loc.  cit.,  p.  204)  describes  in  detail 
a  condition  of  ulceration  which  he  states  is  due  to  retained  discharges 
from  a  rectal  stricture.  He  says :  "  It  appears  as  if  the  superficial  part 
of  the  mucous  membrane  is  only  ulcerated,  the  submucous  tissue  still 
forming  a  distinct  membrane  over  the  muscular  coat,  so  that  the  bowel, 
instead  of  possessing  a  soft,  velvety  lining,  moving  freely  on  the  sub- 
jacent muscular  fibers,  has  a  surface  which,  though  smooth,  gives  a 


NON-SPECIFIC  ULCERATIONS  '2ii'6 

harsh  creaky  sensation  to  the  finger,  and  is  intimately  blended  with 
the  muscular  coat.  This  extensive  superficial  ulceration  may  gradually 
spread  beyond  the  rectum  to  the  colon.  At  a  post-mortem  examination 
the  ulceration  is  found  to  end  very  abruptly.  So  sharp  is  the  line  of 
demarcation  between  the  ulceration  and  the  normal  membrane  that  it 
looks  as  if  cut  with  a  knife."  The  cases  of  this  variety  of  ulcer  have  all 
been  afiiicted  with  cicatricial  stricture  of  the  rectum. 

The  author  has  seen  a  number  of  such  cases  with  superficial  ulcera- 
tion of  the  mucous  membrane  above  the  site  of  the  stricture^,  but  he  is 
not  convinced  of  the  pathology  which  Cripps  indicates — viz.,  that  the 
destruction  of  the  mucous  membrane  results  from  contact  with  purulent 
secretion.  ISTecrosis  of  epithelium  or  ulceration  must  exist  before  puru- 
lent secretion  is  established.  It  appears  more  rational,  therefore,  to 
attribute  these  ulcers  to  the  irritation,  traumatism,  and  infection  pro- 
duced by  forcing  the  fgecal  mass  through  the  narrowed  channel  or  their 
retention  above  the  stricture. 

Strictures  of  the  rectum  are  very  liable  to  be  associated  with  consti- 
tutional conditions,  such  as  tuberculosis,  syphilis,  carcinoma,  or  exhaust- 
ing disease,  which  conditions  also  produce  inflammation  and  ulceration 
of  the  mucous  membrane  of  the  rectum  and  sigmoid.  Moreover,  where 
the  patient  is  debilitated  from  improper  feeding,  irregular  movements 
of  the  bowels,  and  reflex  disturbances  of  the  digestion,  the  mucous 
membrane  of  the  intestine  is  very  likely  to  take  on  a  feeble  circulation 
associated  with  a  cellular  deposit  in  its  glandular  organs,  which  accu- 
mulates until  by  its  pressure  it  causes  a  necrosis  and  subsequent  ul- 
ceration of  the  tissues.  The  fact  that  in  the  case  which  Dr.  Cripps 
quotes  the  stricture  was  cut  and  the  obstruction  and  retention  of  the 
discharge  relieved,  and  yet  the  ulceration  progressed  until  it  involved 
the  whole  of  the  bowel  up  to  the  splenic  fiexure,  proves  that  there  was 
some  other  etiological  factor  to  account  for  it. 

Symptoms. — The  symptoms  of  ulceration  such  as  this  are  practically 
those  of  stricture.  There  is  a  frequent  desire  to  defecate,  and  yet  ina- 
bility to  accomplish  the  same;  only  when  the  bowels  are  fluid  can  the 
patient  succeed  in  having  a  satisfactory  faecal  movement.  When  this 
has  been  accomplished,  his  desire  to  defecate  is  usually  relieved  for 
twelve  to  fourteen  hours,  after  which  the  inclination  recurs  and  fre- 
quent small  passages  of  pus  or  mucus  and  blood  take  place. 

Diarrhoea  alternating  with  constipation,  inability  to  pass  well- 
formed  fgeces,  t}Tnpanites,  and  the  accumulation  of  fsecal  materials  in 
the  intestinal  canal  are  all  sjanptoms  of  this  variety  of  ulceration,  as 
they  are  of  stricture  of  the  rectum.  The  discharge  of  pus  and  blood 
shows  the  presence  of  ulceration.  The  pathology  and  treatment  of  these 
ulcers  will  be  found  in  the  chapter  on  Stricture. 


284  THE   ANUS,   RECTUM,   AND   PELVIC  COLON 

Dysenteric  Ulceration. — This  disease  has  heen  discussed  in  a  previ- 
ous chapter,  but  it  is  necessary  to  say  something  more  concerning  the 
chronic  ulcers  which  follow  it. 

Dysentery,  while  it  ma}',  and  often  does,  involve  the  whole  of  the 
large  intestine,  has  its  seat  most  frequently  in  the  sigmoid  flexure  and 
rectum.  It  is  in  these  lower  portions  of  the  alimentary  canal  that  its 
chronic  results  occur.  This  is  logical  from  the  fact  that  all  of  the  de- 
tritus and  infectious  bacteria  which  are  discharged  or  carried  down- 
ward by  the  peristaltic  action  of  the  gut  above  must  pass  through  and 
lodge  for  greater  or  less  periods  in  these  lower  segments  of  the  gut.  As 
a  result,  therefore,  of  acute,  sporadic,  or  epidemic  dysentery  one  may 
sometimes  see  a  chronic  circumscribed  ulcer  of  the  rectum  or  sigmoid 
with  the  typical  symptoms  of  diarrhea,  pus,  blood,  and  mucus  in  the 
stools.  These  symptoms  accompany  all  forms  of  rectal  ulceration  from 
whatever  cause  they  arise,  and  render  it  difficult  to  distinguish  a  true 
dysenteric  ulceration  from  other  varieties.  Indeed,  ulceration  of  the 
rectum  and  sigmoid  are  often  mistaken  for  and  called  chronic  dysentery. 

The  presence  of  the  amoeba?  dysenterise  or  the  bacillus  of  Shiga  will 
positively  establish  the  dysenteric  nature  of  any  given  ulcer.  As  Kelsey 
states,  there  is  no  doubt  that  the  disease  is  one  of  the  causes  of  chronic 
ulceration  and  stricture.  It  begins  in  an  infiltration  of  the  mucous 
membrane  with  a  fibrous  exudation.  This  infiltration  increases  until 
it  interferes  with  the  blood  supply  of  the  mucous  membrane,  the  latter 
sloughs,  is  cast  off,  and  an  ulceration  results.  If  this  slough  is  super- 
ficial, the  membrane  may  be  soon  restored  to  its  normal  condition,  but 
if  the  infiltration  be  deep  and  involve  the  submucous  tissues,  the  loss 
of  substance  will  be  more  or  less  extensive,  and  cicatrization  and  stricture 
may  result. 

The  ulcers  may  be  small  and  localized,  or  they  may  extend  over  large 
areas,  and  sometimes  entirely  surround  the  canal;  they  may  be  trough- 
like, stellate,  or  irregular  in  shape  (Fig.  86);  they  may  be  single  or 
multiple.  Perforation  has  been  known  to  occur,  but  it  is  not  a  frequent 
accident. 

Habershon  says  "  the  coats  of  the  bowels  may  become  sinuous  ab- 
scesses," so  that  on  dividing  prominent  portions  of  the  mucous  mem- 
brane between  two  ulcers  several  drams  of  pus  may  escape. 

Woodward,  in  his  Surgical  History  of  the  War  of  the  Rebellion,  states 
that  there  has  been  no  case  reported  during  or  since  the  war  of  intestinal 
or  rectal  stricture  having  followed  dysenteric  ulceration.  This  is  only  a 
negative  statement,  however. 

Kelsey  (New  York  Medical  Journal,  1S91.  vol.  i,  p.  733)  reported  a 
case  of  a  strong,  healthy  man,  who  had  had  dysentery  one  year  before, 
and  had  never  recovered.    He  had  lost  30  pounds ;  suffered  from  pain 


NON-SPECIFIC   ULCERATIONS  285 

at  the  end  of  the  spine,  which  was  continuous  during  the  day,  but  not 
so  at  night.  He  had  six  or  eight  stools  during  the  day,  but  at  night  he 
was  not  annoyed.  The  stools  were  foul-smelling,  contained  blood 
and  mucus,  and  were  misshapen.  It  seems  perfectly  clear  from  the 
history  that  the  intestinal  irritation  originated  in  the  dysenteric  attack, 
and  that  the  condition  had  continued  from  that  attack  to  the  time  of  the 
examination.  Local  treatment  having  failed,  Kelsey  at  once  performed 
a  left  inguinal  colotomy,  and  exploring  the  sigmoid  flexure  while  the 
abdominal  wall  was  open,  positively  determined  an  inflammatory  stric- 
ture of  the  lower  segment  of  this  organ,  which  he  states  he  believed  to 
have  been  due  to  dysenteric  ulceration.  The  fact  that  all  who  have  seen 
a  number  of  cases  of  dysentery  have  also  observed  by  rectal  examination 
the  erosion,  inflammation,  and  even  ulceration  which  occur  during  the 
course  of  the  disease,  renders  it  impossible  to  believe  otherwise  than  that 
dysentery  may  result  in  chronic,  extensive  ulceration  with  fibrous  and 
cicatricial  deposit,  which  ends  in  stricture. 

Carcinomatous  "Ulceration. — The  symptoms  of  ulceration  of  the  rec- 
tum are  so  similar  to  those  of  carcinoma  that  it  is  sometimes  very  diffi- 
cult to  determine  between  the  two  conditions.  Absence  of  pain,  morn- 
ing diarrhoea,  discharges  of  mucus,  blood,  and  pus  a,re  common  to  the 
two  conditions,  and  in  any  given  case  suffering  from  such  symptoms  the 
possibility  of  malignant  neoplasm  should  always  be  borne  in  mind. 

The  fact  that  carcinoma  exists  in  the  intestinal  walls,  and  through 
its  pressure  and  interference  with  the  circulation  of  the  parts  causes  a 
breaking  down  and  sloughing  of  the  mucous  membrane  over  this  neo- 
plasm, does  not  prove  that  the  ulcer  itself  is  of  a  carcinomatous  nature. 
Indeed,  it  may  be  a  simple  ulcer  imposed  upon  or  brought  about  by  the 
neoplasm.  The  treatment  of  the  ulcer  in  distinction  to  that  of  the 
carcinoma  may  be  sometimes  of  great  relief  to  the  patient  by  reducing 
the  amount  of  the  discharge,  thus  obviating  too  frequent  and  exhaust- 
ing diarrhoea,  and  keeping  the  intestinal  caliber  sufficiently  open  to 
admit  of  faecal  passages.  The  subject  is  mentioned  here  as  a  type  of 
ulceration  simply  to  impress  upon  the  reader  the  necessity  of  constantly 
keeping  in  view  the  possibility  of  an  ulcerative  condition  being  due  to 
malignant  neoplasm. 

Ulceration  from  Bright's  Disease. — As  mentioned  several  times  before 
in  the  course  of  this  work,  we  frequently  notice  in  autopsies,  where  death 
has  resulted  from  chronic  Bright's  disease,  widespread  ulceration  of  the 
rectum  and  large  intestine.  Dickinson  (Croonian  Lectures  for  1876) 
first  called  attention  to  this  fact.  The  ulceration  is  always  very  ex- 
tensive but  superficial,  involving  only  the  mucous  membrane  of  the 
gut.  It  occurs  in  the  later  stages  of  the  disease,  and  until  within  the 
past  few  years  has  been  rarely  recognized  during  life.     There  is  no 


286  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

tendency  to  perforation  of  the  gut  or  any  thickening  or  induration  of 
its  walls.  The  condition  seems  to  be  due  to  amyloid  or  lardaceous  de- 
generation of  the  mucous  membrane  and  its  glandular  organs. 

Symptoms. — Aside  from  the  general  constitutional  and  local  mani- 
festations of  the  nephritic  condition,  such  as  oedema,  anasarca,  enfee- 
bled heart  action,  debility,  and  reduced  urinary  secretions,  symptoms  of 
indigestion,  a  tendency  to  diarrhoea,  and  great  flatulency  mark  this  com- 
plication of  Bright's  disease.  The  patient  suffers  little  if  any  pain  in 
the  rectum,  but  after  a  period  of  comparative  constipation,  he  gradually 
begins  to  notice  a  looseness  of  the  bowels,  with  excessive  fluid  discharges. 
At  first  these  discharges  are  watery,  but  later  they  become  milky  white 
and  purulent,  and  contain  many  shreds  of  degenerated  or  sloughing 
tissue. 

Examination  of  the  rectum  shows  the  whole  organ  to  be  denuded  of 
its  lining  membrane.  The  sloughing  or  ulceration  is  not  in  patches,  but 
appears  as  a  general  disintegration  of  the  mucous  membrane.  While 
there  are  no  marked  haemorrhages,  the  granulations  bleed  easily  though 
not  excessively  upon  touch.  The  griping  and  tenesmus  are  not  marked, 
but  the  patient  soon  loses  sphincteric  control.  The  fluid  passages  run 
away  from  him  involuntarily,  and  his  condition  is  pitiable  indeed.  Hap- 
pily this  is  one  of  the  latest  stages  of  the  kidney  affection,  and  is  in- 
dicative of  an  early  termination.  In  one  case  which  the  author  saw 
some  years  ago,  the  patient  had  no  idea  that  she  was  suffering  from 
anything  more  than  ansemia  when  she  consulted  him  for  an  uncon- 
trollable desire  to  defecate;  she  was  having  at  the  time  some  six  or  seven 
stools  a  day,  which  did  not  annoy  her  so  much  as  the  fact  that  when  the 
desire  occurred  it  was  impossible  to  control  the  same  or  to  wait  a 
moment.  Examination  of  the  urine  showed  a  large  percentage  of  albu- 
min with  abundant  granular  and  epithelial  casts.  The  mucous  mem- 
brane was  denuded  over  the  first  four  or  five  inches  of  the  rectum,  and 
the  discharges  from  the  intestine  consisted  of  thin  faecal  material  and 
large  quantities  of  pus.  Occasionally  a  little  blood  was  mixed  with  these 
discharges,  although  this  was  not  frequently  the  case.  No  local  or  con- 
stitutional treatment  availed  to  control  the  symptoms,  and  the  patient 
died,  at  the  end  of  four  weeks,  from  uraemic  poisoning. 

Treatment. — The  treatment  of  this  condition  is  hopeless,  but  some- 
thing can  be  done  to  relieve  the  suffering.  The  rectum  and  sigmoid 
should  be  washed  out  with  saline  or  boric-acid  solution  twice  daily,  and 
after  this  has  come  away,  2  to  4  ounces  of  25-  to  50-per-cent  solution 
of  aqueous  fluid  extract  of  krameria  should  be  introduced  into  the  sig- 
moid. A  few  minims  of  deodorized  tincture  of  opium  may  be  added  to 
quiet  peristalsis  and  control  the  diarrhoea.  The  diet  should  be  bland 
and  concentrated,  such  as  milk  and  meat  extracts.     Occasional  saline 


NON-SPECIFIC  ULCERATIONS  287 

purges  to  relieve  the  kidnej^s  of  too  much  work  will  do  no  harm,  but, 
as  a  rule,  it  is  better  to  do  this  by  keeping  the  skin  active.  Medication 
should  be  directed  to  the  kidney  condition.  Tannic  acid,  tannigen,  and 
such  remedies  should  be  avoided,  but  small  doses  of  sulphate  of  copper 
or  nitrate  of  silver  are  admissible,  and  sometimes  they  control  the  diar- 
rhoea remarkably  well. 

Diabetic  Ulceration. — During  the  course  of  diabetic  glycosuria  con- 
stipation often  comes  on  in  consequence  of  the  atonic  state  of  the  bow- 
els, deficient  exercise,  and  the  withdrawal  of  carbohydrate  foods.  Oc- 
casionally, after  this  condition  has  existed  for  some  time,  flatulence  will 
be  markedly  developed,  and  sometimes  excessive  peristalsis  and  the  tor- 
mina ventosa  of  Kussmaul  are  easily  aroused;  with  these  conditions 
there  appears  a  serous  diarrhoea  associated  with  a  discharge  of  pus 
and  blood,  no  satisfactory  explanation  of  which  has  -yet  been  given. 
Clinicians  are  all  aware  of  the  tendency  in  diabetics  to  ulceration  and 
gangrene  of  the  lower  extremities  and  of  the  skin,  especially  where 
any  pressure  is  exercised  upon  the  parts.  Frerichs,  Ferraro,  Kleen,  and 
others  have  reported  ulceration  of  the  intestinal  canal  in  patients  who 
died  from  this  disease.  jSTo  one,  however,  has  established  any  etiological 
relation  between  the  two  conditions. 

It  occurred  to  the  author  some  years  ago  that  pressure  from  the 
hardened  faecal  masses  during  the  constipated  period  of  the  disease 
might  also  cause  ulceration  in  the  rectum  and  sigmoid.  The  examina- 
tion of  three  cases  which  developed  diarrhoea  during  the  course  of  dia- 
betic glycosuria  has  enabled  him  to  verify  this  theory.  In  one  the 
ulceration  was  limited  to  the  rectal  ampulla,  and  extended  over  a  space 
about  the  size  of  a  silver  half-dollar;  it  was  isolated  and  involved  the 
mucous  and  submucous  tissue;  the  edges  were  dry,  and  the  base  feebly 
granulating.  In  the  other  two  cases  the  ulcerations  were  numerous 
and  extensive  throughout  the  rectum  and  sigmoid  flexure.  Strange  to 
say,  just  about  the  time  that  these  occurred,  or  shortly  thereafter,  the 
excretion  of  sugar  almost  entirely  ceased.  In  one  of  these  cases  the 
ulcerations  healed,  but  the  diabetes  recurred,  and  she  succumbed  later 
to  this  disease  with  recurrence  of  the  rectal  complication.  In  the  other 
two  cases  the  diabetes  has  not  recurred,  and  the  patients  have  recov- 
ered froni  the  ulcerative  condition  and  remain  apparently  well.  In  all 
three  cases  there  was  a  history  of  marked  constipation  preceding  the 
diarrhoea. 

In  the  two  cases  with  extensive  ulcerations  the  stools  varied  from 
eight  to  twelve  a  day.  They  were  composed  of  quantities  of  pus  tinged 
with  blood,  and  did  not  possess  any  particularly  feculent  odor.  Once  or 
twice  during  the  day  they  would  pass  more  or  less  hard,  lumpy,  fscal 
material.    In  one  the  muco-cutaneous  margin  was  involved,  occasioning 


288  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

so  much  pain  that  it  was  necessary  to  dihitc  the  spliineter  in  order  to 
give  the  patient  any  rest.  This  patient  also  suffered  from  bedsores, 
owing  to  lying  in  the  recumbent  posture. 

Large  doses  of  codeine  used  to  control  the  glycosuria  seemed  to  have 
no  effect  upon  the  diarrhoea.  Frequent  irrigation,  however,  with  a  20- 
per-cent  solution  of  aqueous  fluid  extract  of  krameria,  together  with 
ichthyol  internally,  succeeded  in  controlling  the  condition,  and  restored 
the  patient  to  health  after  about  twelve  weeks'  treatment.  There  is  no 
distinct  literature  upon  this  subject,  nor  is  it  possible  to  base  any  very 
positive  conclusions  upon  these  limited  observations,  but  the  condition 
is  noted  here  as  it  has  been  observed,  and  a  wider  experience,  it  is  hoped, 
will  determine  its  true  pathology. 

Hepatic  Ulceration. — Ulceration  of  the  rectum  not  infrequently  oc- 
curs in  cases  of  chronic  cirrhosis  of  the  liver.  There  is  no  specific  influ- 
ence in  the  hepatic  disease  to  produce  this  result.  The  obstruction  to 
the  portal  circulation  causes  congestion  and  dilatation  in  the  supe- 
rior hgemorrhoidal  veins,  and  frequent  haemorrhages  from  these  re- 
sult. The  infection  of  the  rupture  in  the  vein  causes  the  ulceration. 
These  generally  assume  the  form  of  ulcerated  haemorrhoids.  They 
occur  upon  the  summit  of  the  hgemorrhoidal  mass,  and  not  between 
them. 

Treatment. — The  treatment  of  this  condition  consists  principally 
in  attacking  the  disease  of  the  liver.  One  may  be  tempted  to  operate 
upon  the  haemorrhoidal  condition,  and  thus  remove  the  ulceration  and 
check  the  haemorrhages.  This,  however,  is  not  ordinarily  a  wise  pro- 
cedure. As  stated  in  the  chapter  upon  Hgemorrhoids,  the  checking  of 
these  periodic  losses  of  blood  is  likely  to  be  followed  by  acute  anasarca 
and  rapid  aggravation  of  the  hepatic  disease. 

The  bowels  should  be  kept  freely  open  and  the  rectum  irrigated 
daily  with  antiseptic  solutions.  If  there  is  a  tendency  for  the  haemor- 
rhoids to  become  strangulated  by  spasm  of  the  sphincter,  this  muscle 
may  be  stretched.  Beyond  this,  operative  interference  is  likely  to  do 
more  harm  than  good. 

Trophic  Ulceration. — In  the  chapter  upon  Colitis  we  have  already 
called  attention  to  the  trophic  ulcerations  of  the  large  intestine,  and 
have  referred  to  them  as  occurring  also  in  the  rectum  and  sigmoid  flex- 
ure. Ackland  and  Targett  both  claimed  that  ulceration  of  the  large 
intestine  may  be  due  to  diseases  of  the  central  nervous  SA^stem,  and 
report  cases  which  seem  to  confirm  their  opinion.  White  has  reported 
two  cases  occurring  in  Guy's  Hospital  which  seem  to  corroborate  this 
view. 

Cowan  and  Eurich  state  that  the  general  lowered  vitality  of  the 
insane  renders  them  an  easy  prey  to  all  sorts  of  disease,  and  that  the 


NON-SPECIFIC  ULCERATIONS  289 

cases  of  ulceration  of  the  rectum  and  colon  in  this  class  of  patients 
is  more  likely  clue  to  some  other  cause,  such  as  traumatism  and  infec- 
tion, than  to  trophic  neuroses. 

Ulcerations  of  the  rectum  occurring  in  spinal  disease  and  neuras- 
thenia have  been  referred  to,  but  there  is  no  reason  to  suppose  that  they 
did  not  result  from  the  usual  causes.  On  the  whole,  while  there  are  some 
evidences  in  favor  of  this  type  of  ulceration,  there  are  no  characteristic 
symptoms  or  positive  proofs  that  it  actually  exists. 

It  may  be  worth  while  to  mention  in  this  connection  two  cases  of 
ulceration  of  the  rectum  and  sigmoid  following  injiiries  to  the  spinal 
cord,  with  paraplegia  and  temporary  loss  of  sphincteric  control.  In 
both  of  these  cases  the  paralvtic  symptoms  disappeared,  but  there  was 
a  marked  decrease  in  sensibility  about  the  anus.  In  one  there  were 
numerous  ulcerative  patches  throughout  the  rectum  and  in  the  lower 
portion  of  the  sigmoid  flexure.  There  was  no  tuberculosis  or  syphilis 
in  either  case  to  account  for  the  condition.  Without  being  able  to  dis- 
cover any  other  cause,  it  is  thought  possible  that  these  might  be  cases 
of  trophic  ulceration  due  to  injury  of  the  cord. 

Marasmic  TJlceration. — Some  years  ago  it  was  the  privilege  of  the 
author  to  make  autopsies  on  a  number  of  children  who  had  died  from 
the  condition  known  as  marasmus.  The  ages  extended  from  two 
months  to  three  and  a  half  years.  A  number  of  these  cases  turned 
out  to  be  tuberculous,  the  mesenteric  glands  being  enlarged  and  con- 
taining tubercle  bacilli.  In  others  there  were  gummatous  develop- 
ments in  different  portions  of  the  body  which  indicated  syphilitic  dis- 
ease. In  5  cases,  however,  there  was  no  evidence  of  either  of  these 
specific  affections.  The  children  seemed  to  waste  away  and  die  simply 
from  malassimilation  and  exhaustion. 

An  examination  of  the  intestines  in  these  cases  showed  in  3  of 
them  extensive  ulceration  of  the  rectum,  sigmoid,  and  colon.  In  one 
case  the  ulcers  extended  well  into  the  ileum.  The  condition  resembled 
very  much  that  seen  in  the  late  stages  of  Bright's  disease.  There  were 
left  here  and  there  patches  of  mucous  membrane,  but  these  were  always 
covered  with  a  sort  of  flaky  deposit  resembling  very  much  the  beginning 
of  diphtheritic  membranes.  Microscopic  examination,  however,  failed 
to  reveal  any  specific  bacilli  in  them.  The  walls  of  the  gut  were  not 
infiltrated  or  thickened,  and  there  was  no  approach  to  perforation  in 
any  of  the  cases.  Two  of  these  cases  were  being  treated  for  summer 
diarrhoea  at  the  time  of  their  death.  The  stools,  however,  differed 
from  the  ordinary  flocculent,  green  ones  of  this  disease,  in  that  they 
contained  considerable  quantities  of  pus  tinged  with  blood  and  very 
little  mucus.  The  explanation  of  this  latter  fact  lies  in  the  destruction 
of  the  epithelial  layer  of  the  mucous  membrane  and  the  consequent 
19 


290  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

absence  of  goblet-cells.  In  all  of  the  cases  there  was  a  history  of 
gradual  wasting  disease  before  the  diarrhoea  began. 

The  stools  at  first  had  contained  considerable  mucus  with  blood, 
but  they  had  gradually  become  thinner,  containing  more  pus  than 
mucus,  until  in  the  later  stages  they  were  almost  entirely  composed 
of  pus  and  undigested  milk.  The  condition  is  undoubtedly  the  result 
of  impaired  circulation,  probably  accompanied  by  thromboses  of  the 
intestinal  veins. 

The  symptoms  are  those  of  a  gradvially  increasing  diarrhoea  occur- 
ring in  marasmic  children.  There  is  little  pain  or  griping,  and  the 
stools  gradually  change  from  the  green,  mucous  type  to  pus,  serum, 
and  undigested  food. 

It  is  impossible  to  lay  down  any  definite  lines  of  treatment,  as 
every  method  failed  in  the  cases  seen.  Seasoning  from  the  condition 
observed,  however,  one  would  suppose  that  some  relief  might  be  ob- 
tained by  flushing  the  colon  freely  with  saline  solutions.  This  would 
have  to  be  done  with  the  child  in  the  knee-chest  posture  and  through  a 
long  rectal  tube,  inasmuch  as  the  sphincters  are  always  so  relaxed  that 
the  fluid  would  flow  out  immediately  if  injected  into  the  rectal  ampulla. 
The  general  treatment  of  the  constitutional  condition  will,  however,  do 
more  for  the  patient  than  any  local  applications.  For  this,  liowever, 
the  reader  must  be  referred  to  works  upon  diseases  of  children. 


CHAPTEE    IX 

FISSURE  IX  AX 0— IRRITABLE    VLCER—IXTOLERABLE    VLCER 

The  terms  which  head  this  chapter  haye  been  used  by  various 
writers  to  describe  a  type  of  anal  ulcer  characterized  by  acute  pain 
during  or  after  stool.  Gosselin  first  distinguished  between  the  acutely 
sensitive  lesions  at  this  point  and  those  which  were  less  so^  calling 
them  tolerant  and  intolerant  ulcers.  Allingham  designates  the  sensi- 
tive t^-|^e  as  "  irritable  ulcer."  ^lolliere  suggested  the  better  terms 
tolerable  and  intolerable,  holding  properly  that  all  ulcerations  of  this 
region  occasioned  some  pain.*  The  word  fissure  signifies  a  crack  or 
elongated  break  in  the  tissues.  It  may  occur  anwhere  in  the  body, 
but  in  common  parlance  it  is  applied  generally  to  the  lesion  in  the 
anus.  It  is  an  ulcer,  but  distinct  from  those  destructive  and  extensive 
types  which  have  been  described  in  the  previous  chapters.  Technically 
it  is  limited  to  the  sulci  between  the  radial  folds;  it  spreads  up  and 
down  but  not  circularly,  does  not  involve  the  tegument  covering  the 
folds  and  columns  of  Morgagni,  and  is  painful  at  or  after  stool  or  upon 
the  escape  of  gases  from  the  anus. 

It  occurs  in  all  ages  and  conditions  of  life,  but  is  more  frequent 
in  the  young  than  in  the  very  old.  In  infants  the  disease  is  very  likely 
to  be  the  result  of  hereditary  syphilis,  but  this  is  not  necessarily  the 
case.  It  is  chiefly  found  in  adult  life  and  in  women,  especially  during 
the  child-bearing  period. 

Sex  does  not  seem  to  influence  it  materially.  Allingham  says  it 
is  more  frec[uent  in  women,  and  Goodsall,  working  in  the  same  hospital, 
finds  it  oftener  in  men:  in  359  cases  of  fissure  he  found  it  190  times 
in  men  and  139  in  women.  In  324  cases  collected  by  the  author  from 
different  sources  it  occurred  176  times  in  women  and  148  times  in  men. 

It  may  be  single  or  multiple,  but  the  typical  painful  fissure  is 
nearlv  always  single.  The  multiple  variety  is  rare  except  in  atrophic 
catarrh,  gonorrhoea,  and  syphilis.  In  these  conditions  multiple  fissure- 
like  ulcerations  are  comparatively  frequent.  Goodsall  found  in  221  cases 
that  fissures  were  single  in  208;  there  were  2  fissures  in  12  cases,  and  3 
in  only  1. 

291 


292 


THE  AXUS,  RECTUM,   AND   PELVIC   COLOX 


Shape  of  Ulcers. — Much  importance  has  been  attached  by  writers 
upon  this  subject  to  the  shape  of  the  lesions.     Most  authors  attempt 
to  confine  the  term  to  those  linear  or  elliptical  ulcers  which  are  con- 
fined to  the  groove  be- 
tween  two   anal   folds 
(Fig.    101).     Recently, 
however,  no  particular 
importance  is  attached 
to  the  shape.     It  may 
be  linear,  pear-shaped, 
elliptical,     or     round. 
Quenu  and  Hartmann 
in   an   elaborate   study 
of  a  number  of  cases 
have  come  to  the  con- 
clusion   that    this    fis- 
sure-like  or   elongated 
shape  is  only  apparent, 
and   that   where    it    is 
dissected  out  and  laid 
flat  upon  a  block  the 
ulcer  assumes  a  circu- 
lar or  elliptical  form. 
It  is  the  site  between 
the   radial   or   mucous 
folds,  within  the  grasp 
of  the  sphincter,  which 
gives  it  the  elongated 
shape  and  characterizes 
it.      In   its   other  fea- 
tures it  does  not  differ  from  any  simple  ulcer;  the  edges  are  generally 
inflamed  and  slightly  elevated,  but  not  indurated;  they  may  be  ragged 
(Fig.  102)  and  appear  slightly  undermined,  but  the  latter  feature  disap- 
pears when  the  ulcer  is  stretched  open.    The  base  is  either  a  bright-red 
granulating  surface  which  bleeds  easily  upon  touch,  or  it  may  be  com- 
posed of  grayish,  fleshy  granulations  covered  by  a  thick  pus  or  pseudo- 
membrane.     The  elevated  edges  are  folded  or  tucked  in  by  the  con- 
traction of  the  sphincter,  so  that  they  rest  upon  the  base  of  the  ulcer, 
thus  irritating  it  and  preventing  healing  as  well  as  causing  pain. 

At  the  lower  end  of  the  fissure  there  is  frequently  a  h3'pertrophy 
of  the  skin  or  muco-cutaneous  tissue  which  resembles  an  external  pile, 
and  has  been  called  by  Brodie  the  sentinel  pile  (Fig.  103).  This  may 
be  divided  into  two  ear-like  flaps  by  the  fissure;  it  is  always  painful 


Fig.  101. — FisscRE  ix  Axo. 


FISSURE   IN   AXO 


293 


to   the    touch,    and    when    dragged   upon    it    brings    on    characteristic 
pains. 

Location. — The  site  of  the  fissure  in  ano  is  variable  and  may  occur 
at  any  point  from  the  cutaneous  margin  to  the  upper  limits  of  the 
columns  of  Morgagni;  the  majority  begin  just  above  the  ano-rectal 
line  and  extend  downward.  It  may  also  occupy  any  point  in  the  anal 
circumference.  In  men  they  are  most  frequently  seen  at  or  near  the 
posterior  commissure,  and  rarely  upon  the  sides  or  anteriorly.  In 
women  they  are  comparatively  often  seen  at  the  anterior  commissure. 
In  132  cases  in  men  recorded  by  Goodsall,  the  fissure  w^as  found  at  the 
anterior  commissure  but  once,  and  in  89  women  it  was  found  there 
12  times.  The  significance  of  these  locations  will  be  appreciated  when 
the  etiology  and  symptomatology  of  the  disease  are  studied. 

Etiology. — If  all  ulcers  of  the  anal  canal  are  considered  to  be  fissures 
it  will  be  necessary  to  invoke  as  etiological  factors  catarrhal  diseases, 
gonorrhoea,  chancroid,  syphilis,  tuberculosis,  etc.  The  typical  anal  fis- 
sure is  an  ulceration  entirely  distinct  from  these  types,  not  in  its  shape, 
for  all  of  them  may  assume  the  elliptical  or  irregular  shape;  not  in  its 
depth,  for  this  is  variable  in  all  varieties;  but  in  its  etiology,  its  symp- 
tomatology, and  progress.  From  day  to  day,  if  one  carefully  observes  a 
simple  traumatic  fis- 
sure of  the  anus,  he 
may  see  signs  of  cica- 
trization at  its  mar- 
gin which  comes  and 
lasts  for  short  jDcriods, 
only  to  break  down 
again.  Sometimes 
even  the  ulcer  will 
heal  completely  and 
remain  so  for  a  short 
period,  breaking  down 
again  under  the  influ- 
ence of  hard  f^cal 
passages  and  strain- 
ing at  stool.  Surgi- 
cal operations  may  result  in  fissure-like  ulcerations,  but  eventually  these 
heal  in  the  majority  of  cases  without  leaving  a  typical  cicatrix. 

Fissures  may  originate  in  any  wound,  excoriation,  eruption,  or 
inflammation  around  the  anus.  Anything  which  weakens  the  tissues 
and  renders  them  liable  to  abrasion  will  act  as  a  predisposing  cause. 
The  exciting  cause,  however,  is  nearly  always  the  passage  of  hard  faecal 
masses  with  or  without  foreign  bodies  in  them.    The  fact  that  women 


Fig.  102.— Ieregulae  Fissure  or  Irritable  Ulcer  of  Aires. 


294  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

are  more  frequently  constipated  than  men  will  account  for  the  appar- 
ently greater  proportion  of  fissures  in  this  sex.  Injury  to  the  mucous 
membrane  by  syringe-tips,  straining,  or  a  severe  sneeze  or  cough,  may 
rupture  the  delicate  mucous  membrane  of  the  anus  and  cause  fissure. 


I 


Fig.  103. — Fissitre  with  SEimifEL  Pile  iif  Syphilitic  Chilb. 

Allingham  states  that  gelatinous  and  fibrous  polypi  are  not  at  all  un- 
common causes  of  fissure:  "  The  polypus  is  usually  situated  at  the 
upper  or  internal  end  of  the  fissure,  but  it  may  be  on  the  opposite 
side  of  the  rectum."  Whatever  causes  narrowing  of  the  anal  canal, 
such  as  congenital  malformation,  hypertrophy  and  contracture  of  the 
sphincter  or  levator  ani  muscle,  and  stricture,  may  result  in  fissure. 
The  condition  may  also  result  from  parturition,  the  passage  of  the 
child's  head  throiigh  the  vagina  so  distending  the  rectum  as  to  tear 
the  mucous  membrane.  It  is  also  said  to  result  from  malpositions  of 
the  uterus,  such  as  anteversion  and  retroversion. 

The  fact  that  a  large  majority  of  patients  suffering  from  fissure  are 
also  afflicted  with  a  greater  or  less  degree  of  ha?morrhoidal  disease 
would  indicate  that  there  was  some  etiological  relation  between  the 
two.  The  statement  of  Quenu  and  Hartmann  (op.cii.,  421)  that  70 
to  80  per  cent  of  fissures  are  due  to  hemorrhoids  does  not  seem  reasona- 
ble; it  is  more  likely  that  the  irritation  produced  by  the  fissure  results 


FISSURE  IN  ANO 


295 


in  a  hyperaemia  and  congestion  about  the  margin  of  the  anus,  and  is 
thus  the  cause  rather  than  the  result  of  hsemorrhoids.  The  author 
has  seen  a  number  of  cases  of  fissure  in  which  the  heemorrhoidal  symp- 
toms— protrusion,  bleeding,  and  backache — all  came  on  after  the  original 
symptoms  of  fissure.  The  costiveness  which  causes  the  fissure  will 
also  account  for  the  hsemorrhoidSj  so  the  relation  therefore  appears  co- 
incident rather  than  etiological.  Boyer's  theory  that  the  fissure  is  due 
to  spasmodic  contraction  of  the  sphincter  puts  the  cart  before  the 
horse  and  is  no  longer  considered  seriously. 

Ball  has  advanced  the  idea  that  typical  fissures  are  due  to  tearing 
of  the  crypts  of  Morgagni.  He  says  that  they  are  brought  about  by 
the  lodgment  of  small  faecal  masses  in  these  little  pockets,  which  being 
pressed  upon  by  hard  stools  cause  the  edges  of  the  valves  to  tear;  this 
rent  is  gradually  extended  by  every  subsequent  passage  until  the  whole 
depth  of  the  crypt  is  torn  through  and  the  muco-cutaneous  tissue  of  the 
anus  is  thus  involved  (Fig.  104).  This  theory  is  very  plausible,  and  the 
frequency  with  which  fissures  occur  at  the  anterior  and  posterior  com- 
missure is  entirely  in  keeping  with  the  anatomical  fact  that  the  crypts 
are  more  highly  developed  in  these  areas  than  in  any  other  portion 
of  the  rectum.  A  series  of  examinations  instituted  after  the  publica- 
tion of  Ball's  article 
(Brit.  Med.  Jour.,  1891, 
vol.  ii,  p.  583)  have 
shown  that  upon  each 
side  of  the  posterior 
commissure  there  is  al- 
most always  a  well-de- 
veloped valve  of  Mor- 
gagni and  one  directly 
in  the  middle  line  of 
the  anterior  commis- 
sure in  women;  and  a 
study  of  all  the  cases  of 
fissure  observed  since 
has  shown  that  the  ma- 
jority occur  at  these  two  points.  Moreover,  a  careful  examination  of 
fissures  will  frequently  show  two  little  papillae  or  teats,  which  would 
indicate  the  tearing  through  of  a  fold  of  the  muco-cutaneous  tissue; 
sometimes  this  fold  is  not  entirely  torn  through,  and  the  fissure  presents 
a  slight  pocket  underneath  the  lower  border  accompanied  with  hyper- 
trophy of  the  skin  externally.  This  hypertrophy  represents  the  well- 
known  sentinel  pile  of  Brodie  which  has  been  described.  From  all  these 
facts  it  seems  reasonable  to  conclude  that  while  fissures  mav  occur  at 


Fig.  104.- 


-FlSSURE    PRODUCED    BY    EeNT   IN    CrYPT   OF 

Morgagni. 


296  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

any  portion  of  the  circumference  of  the  rectum  through  a  soh;tion  of 
continuity  in  the  covering  membrane  from  any  cause,  it  is  likely  that 
many  cases  are  due  to  the  tearing  of  these  little  crypts  as  claimed  by 
Ball.  There  remain,  however,  a  large  number  which  occur  in  the  very 
middle  of  the  posterior  commissure,  above  which  point  there  is  no  crypt; 
these  are  explained  by  the  direction  of  the  canal  above  the  commissure, 
which  is  backward,  and  consequently  the  mass  exerts  its  greatest  pres- 
sure there. 

Pathology. — The  pathological  changes  in  fissure  vary  from  the 
slightest  abrasion  to  deep  ulceration  and  destruction  of  tissue.  In  some 
only  the  most  superficial  layer  of  the  muco-cutaneous  tissue  is  involved, 
while  in  others  even  the  muscular  fibers  themselves  are  either  laid  bare 
or  become  involved  in  an  inflammatory  process  accompanied  by  fibrous 
deposits  and  alterations  in  the  vascular  and  nerve  supply.  In  the 
superficial  variety,  those  which  may  be  called  acute,  there  is  no  indura- 
tion of  the  base,  no  thickening  of  the  edges,  and  no  great  hypertrophy 
of  the  sphincter  muscle.  In  the  chronic  state,  however,  the  edges  of 
the  ulcers  are  elevated,  irregular,  and  thickened,  the  base  is  hard  and 
inelastic,  and  the  sphincter  muscle  is  hypertrophied  and  very  resisting. 
In  this  state  it  might  be  very  difficult  to  distinguish  the  simple  fissure 
from  a  true  Hunterian  chancre.  The- time  which  it  has  existed  and  the 
absence  of  other  specific  manifestations  during  that  period  should 
decide  this  question.  The  elongated  ulcer  occurring  between  the  radial 
folds  low  down  occasions  a  higher  degree  of  sphincteric  spasm  and 
hypertrophy  than  does  the  small  round  ulcer  which  occurs  above  the 
ano-rectal  line.  There  is  also  more  induration  and  inflammatory  in- 
volvement of  the  neighboring  tissue  in  the  linear  than  in  the  round 
ulcer. 

Microscopic  examination  of  excised  fissures  has  been  made  by  M. 
Hartmann  {op.  cit.,  p.  422);  upon  the  surface  of  the  ulceration  there 
was  a  granular  layer  of  round  cells  of  unequal  thickness  lacking  in 
places;  below  this  was  a  fibrous  layer  in  which  were  scattered  numbers 
of  round  cells  and  fusiform  granules  crossed  by  bosselated  blood-vessels 
running  parallel  to  the  surface;  still  lower  was  a  layer  of  smooth  mus- 
cular fibers  more  or  less  separated  from  one  another  by  fibrous  tissue, 
and  below  this  a  cellular  adipose  layer  in  which  ramified  the  blood- 
vessels with  their  tunics  and  primitive  nerve-roots.  In  the  adipose 
region  the  nerves  and  the  vessels  appeared  normal,  but  in  tlie  deep 
muscular  layer  the  nerve-trunks  were  surrounded  by  fibrous  material 
(Fig.  105).  They  were  altered  and  granular,  and  distinguished  by  their 
lamellar  sheath,  and  showed  interstitial  and  intrafascicular  neuritis 
(Fig.  106).  The  mucous  and  muco-cutaneous  border  of  the  ulceration 
presented  a  cavernous  transformation,  the  epithelium  assumed  a  strati- 


FISSURE  IN  ANO 


297 


Fig.  105. — Pekineukitis  in  Chronic  Fissure 
(Quenu  and  Hartmann). 


fied,  translucent  appearance,  the  prolongations  of  the  epidermis  were 
destroyed,  and  there  was  an  infiltration  with  granular  cells  accompanied 
by  venous  thromboses  and  small  intercellular  hemorrhages. 

There  was  no  evidence  in  any  of  the  sections  of  exposed  nerve-ends. 
The  history  of  the  cases  from  which  these  sections  were  taken  is  not 
given  in  Hartmann's  report.     It  is  well  known  clinically  that  the  pain 
in  fissures  varies  according  to  their  duration;  at  first  it  is  burning,  cut- 
ting,  and  lasts  only  a  short  time;  but  after  they  become  chronic,  it  is 
a  dull,  throbbing  ache  which  radiates  to  the  back  and  down  the  legs. 
In  the  first  a  sensitive  nerve-end  may  be  found  exposed,  whereas  in  the 
second  this  sensitive  nerve-end 
may   have   been    destroyed   by 
the  ulcerative  process,  and  the 
peri-   and   interstitial   neuritis 
may  have  taken  place  in  the 
nerve  deeper  down.     It  would 
have  proved   more   interesting 
and    instructive    if    Hartmann 
had  taken  a  series  of  cases  in 
their  initial  stages  as  well  as 
these  apparently  chronic  cases 
from  which  he  made  the  mi- 
croscopic examinations.  At  the 
same  time  these  studies  are  of 
the    greatest    importance,    and 
enable  us  to  explain  in  a  meas- 
ure the  old  aching,  throbbing, 
dull  pain  which  follows  defeca- 
tion  in    chronic    fissure,    even 
after  they  have  healed  by  cica- 
trization.    On  the  other  hand, 
its  pathology  will  not  explain 
the  acute,  burning,  tearing  pain 
which  occurs  in  the  early  stages  of  acute  fissure,  because  in  these  cases 
there  is  no  induration,  no  hypertrophy  of  the  sphincter,  and  no  possi- 
bility of  the  neuritis  as  above  described.     Here  it  is  simply  a  question 
of  a  raw  surface  exposed  to  the  irritating  action  of  the  fjecal  passages, 
which  surface  differs  in  no  wise  from  that  at  any  other  portion  of  the 
body,  save  that  the  tissues  are  somewhat  more  highly  endowed  with 
sensitive  nerve-ends.    It  is  impossible,  therefore,  to  conceive  of  a  lesion 
in  these  tissues  without  an  exposure  of  some  of  those  numerous  nerve 
filaments  which  supply  the  anal  canal,  and  this  exposure  accounts  for 
the  characteristic  pain  in  the  early  stages. 


Fig.  106. — Intrafascicular  Neuritis  in  Chronic 
Fissure  (Quenu  and  Hartmann). 


298  THE   ANUS,  RECTUM,   AND   PELVIC   COLON 

Symptoms. — As  a  rule,  patients  can  not  say  when  the  tirst  symptoms 
of  fissure  begin.  Occasionally  one  will  recognize  a  time  when  during 
a  difficult  faecal  passage  there  was  a  sensation  of  something  giving  way, 
after  which  there  occtirred  a  slight  discharge  of  blood  and  recurrent 
pain  at  each  stool.  Such  a  history,  however,  is  rare.  Ordinarily  he 
will  state  that  for  some  time  he  has  noticed  either  itching  or  burning 
after  stool,  accompanied  with  blood  or  mucus,  and  that  he  has  a  small 
pile  which  is  either  always  swollen  or  which  swells  after  defecation. 
The  bleeding  is  generally  confined  to  one  or  two  drops,  or  simply  a 
staining  of  the  detergent  material.  The  discharge  of  pus  may  not  be 
sufficient  even  to  soil  the  linen.  Constipation  will  be  complained  of, 
but  if  one  sifts  the  facts,  it  will  be  seen  that  this  has  been  brought  on 
more  by  the  fear  of  pain  following  faecal  movements  than  by  any  inac- 
tivity of  the  bowels;  it  is  an  acquired  habit  rather  than  a  functional 
disease.  In  the  beginning  the  patient  could  and  would  have  had  regu- 
lar movements  of  the  bowels  had  it  not  been  for  this  fear  of  pain; 
there  is  in  most  cases  absolutely  no  obstruction  to  the  f?ecal  passages, 
and  in  the  early  stages  no  lack  of  moisture  and  lubrication  in  the 
intestinal  canal;  it  is  simply  a  matter  of  voluntarv  control.  The  result 
of  this  is  that  the  faecal  passages  become  more  and  more  dry  the 
longer  they  are  retained.  They  are  thus  made  harder  and  more 
irritating,  and  finally  when  a  movement  does  take  place,  the  irrita- 
tion is  much  more  severe  than  it  would  have  been  had  regular  move- 
ments occurred,  and  the  injury  to  the  fissure  or  ulcerated  membrane 
is  greater. 

Pain. — The  pain  associated  Avith  fissure  is  very  variable  in  time,  na- 
ture, and  duration.  It  may  come  on  at  stool,  immediately  thereafter, 
or  half  an  hour  to  an  hour  later.  It  may  be  acute,  cutting,  tearing,  as 
if  a  wound  were  being  pulled  asunder,  or  it  may  be  a  burning,  hot,  irri- 
tating feeling  accompanied  with  spasm  and  bearing-down  sensations. 
Finally,  it  may  have  none  of  these  characteristics,  but  assume  a  dull, 
heavy  ache,  with  throbbing  and  distress  similar  to  an  aching  tooth. 
The  time  which  the  pain  lasts  is  also  as  variable  as  its  nature.  Some- 
times it  lasts  for  only  a  few  minutes,  and  the  patient  is  then  able  to 
go  about  his  business  without  any  further  disturbance  until  the  next 
stool.  At  other  times  the  pain  and  smarting  are  so  severe  that  he  is 
unable  to  move  from  his  position  at  the  toilet,  or  must  seek  his  bed,  and 
lie  there  from  half  to  three-quarters  of  an  hour  until  the  acute  agony 
has  passed  away.  After  this  he  is  comparatively  comfortable  for  the 
rest  of  the  day.  In  others  still  the  pain  does  not  come  on  for  some  little 
time  after  the  fscal  movement,  when  it  begins  to  smart  and  burn,  this 
sensation  gradually  changing  into  an  aching,  throbbing  distress  about 
the  anus  and  sacrum,  which  condition  may  last  for  several  hours,  or 


FISSURE  IN  ANO  299 

even  in  some  cases  all  day  long.  Certain  patients  are  never  free  from 
discomfort. 

There  is  a  pretty  clear  relationship  between  these  pains  and  the 
character  of  the  fissure.  Those  acute  pains  lasting  for  only  a  few  mo- 
ments are  ordinarily  due  to  superficial  fissures  which  involve  the  upper- 
most layers  of  the  muco-cutaneous  tissues,  heal  partially  or  entirely 
from  day  to  day,  and  recur  with  each  hard  stool.  They  can  be  pro- 
duced by  forcibly  stretching  the  anal  folds  apart.  Such  fissures  are  fre- 
quently associated  with  atrophic  catarrh  and  late  syphilis.  The  pains 
which  come  on  just  after  stool,  and  last  for  half  an  hour  or  more,  are 
ordinarily  due  to  an  ulceration  between  the  radial  folds  of  the  rectum, 
especially  in  the  posterior  commissure;  there  is  a  slight,  red,  granu- 
lated base,  thickening  of  the  edges,  and  a  sentinel  pile,  or  two  little 
teats  at  its  lower  end.  The  dull,  aching,  throbbing  pain  which  comes 
on  some  time  after  stool  is  generally  due  to  a  fissure  or  ulceration  situ- 
ated in  the  upper  portion  of  the  anus,  and  involves  the  internal  and  the 
upper  fibers  of  the  external  sphincter.  It  is  ordinarily  of  long  standing, 
deeper  and  more  indurated  than  the  previous  variety,  but  its  edges  are 
not  so  elevated  and  thickened,  and  it  does  not  involve  the  skin  at  all, 
and  can  only  be  seen  by  the  use  of  a  speculum  or  forcibly  stretching  the 
anus  apart.  These  late  pains,  occurring  some  time  after  a  fgecal  move- 
ment, indicate  that  the  ulceration  is  high  up,  while  those  occurring  im- 
mediately thereafter  would  indicate  a  lower  situation.  In  general,  how- 
ever, it  may  be  said  that  the  acuteness  and  severity  of  the  pain  is  in  direct 
proportion  to  the  nearness  of  the  ulcer  to  the  anal  margin.  The  more 
of  the  muco-cutaneous  tissue  involved  the  greater  will  be  the  pain.  The 
application  of  this  is  clearly  brought  out  in  the  chapter  upon  Anatomy, 
where  it  is  shown  that  the  sensitive  nerve-fibers  ajDproach  the  anus 
from  below,  and  are  distributed  in  a  gradually  decreasing  ratio  as 
we  ascend  into  the  anal  canal,  disappearing  almost  entirely  after  the 
mucous  membrane  has  been  reached. 

Reflex  Symptoms. — With  the  local  symptoms  of  fissure  a  variety  of 
reflex  phenomena  occurs,  sometimes  even  more  annoying  than  the  fissure 
itself.  Dysuria  and  painful  urination  are  among  the  most  frequent 
complications.  The  first  case  of  fissure  that  the  author  treated  was  a 
man  who  complained  of  symptoms  of  urethral  stricture,  and  who  had 
been  treated  for  the  same  for  a  long  time  without  any  material  benefit. 
He  was  an  orderly  at  the  Blockley  Hospital  in  Philadelphia,  and  close 
questioning  revealed  the  fact  that  his  urethral  symptoms  were  always 
more  marked  at  the  time  of  and  just  after  his  faecal  passages,  and  that 
at  periods  the  farthest  removed  from  the  stool  he  was  comparatively  free 
from  his  urethral  symptoms.  Examination  of  the  man's  rectum  demon- 
strated the  existence  of  a  small  indurated  fissure  at  the  anterior  com- 


300  THE  ANUS,  RECTUM,   AND   PELVIC   COLON 

missure  of  the  amis.  Incision  of  this  soon  resulted  in  its  cure,  and  for 
two  years  thereafter  the  patient  was  absolutely  free  from  any  urethral 
or  urinary  symptoms. 

It  is  not  necessary,  however,  that  the  fissure  should  be  in  the  ante- 
rior commissure  to  produce  these  reflex  urinary  disturbances,  as  prox- 
imity is  not  the  cause.  The  origin  of  the  nerve  supply  to  both  sets  of 
organs  being  practically  the  same  in  the  spinal  cord,  irritation  of  the 
nerve-ends  in  one  is  likely  to  be  reflected  in  the  other. 

Uterine  and  bearing-down  pains  often  occur  as  a  result  of  fissure  in 
ano.  Backache  and  neuralgia  shooting  down  the  leg,  indeed  all  over 
the  body,  may  be  the  result  of  one  of  these  nagging,  irritable  ulcers  of 
the  anus.  These  widespread  and  vague  disturbances  are,  of  course,  due 
in  a  measure  to  the  nervous  exhaustion  and  strain  produced  by  long- 
continued  suffering  and  irregular  action  of  the  bowels.  Facial  and  occip- 
ital neuralgia,  spinal  irritation,  and  temporary  strabismus  have  been 
known  to  disappear  almost  immediately  after  operations  for  fissure;  it 
is  not  asserted  that  the  latter  was  the  cause,  but  it  certainly  seemed  to  be. 

Diagnosis. — The  diagnosis  of  fissure  is  considered  very  simple.  It 
is  often  made  simply  from  the  description  of  pains  after  stool,  but  pa- 
tients have  these  from  many  causes;  foreign  bodies,  stricture,  chan- 
croids, gonorrhoea,  syphilis,  and  eczema  all  produce  them.  While  these 
symptoms  are  of  the  utmost  importance,  one  should  not  make  a  final 
diagnosis  without  a  careful  local  examination.  This  should  be  insisted 
upon  in  every  case  in  which  there  are  symptoms  of  rectal  disease,  and  in 
none  is  it  more  important  than  in  this  condition ;  first,  because  mistakes 
in  rectal  diseases  are  likely  to  prove  rapidly  disastrous ;  and,  second, 
because  in  this  particular  disease  local  treatment  or  operation  is  the 
only  reliable  means  of  cure,  and  therefore  nothing  can  possibly  be  gained 
by  delay. 

To  examine  a  patient  for  fissure,  the  semiprone  position  is  the  most 
convenient.  The  patient  should  be  laid  upon  his  left  side,  the  hips 
elevated  upon  pillows,  the  thighs  flexed  upon  the  abdomen,  and  the  left 
arm  throAvn  backward,  so  that  the  trunk  rests  practically  upon  the 
breast.  The  buttocks  should  at  first  be  pulled  gently  apart  and  the  ex- 
ternal surface  of  the  anus  examined.  If  there  be  a  sentinel  pile  it  can 
be  easily  recognized,  or  if  the  ulceration  involve  the  perianal  tissue  it 
will  also  be  clearly  seen. 

Palpation  around  the  anus  will  not  only  reveal  the  hypertrophied 
and  hardened  condition  of  the  sphincter  muscle,  but  it  will  usually  en- 
able one  to  determine  the  probable  point  at  which  one  may  expect  to 
find  the  cause  of  the  pain.  Pressure  upon  the  margin  of  the  anus  always 
gives  pain  just  below  the  site  of  an  ulceration,  even  though  the  ulcer 
itself  is  not  pressed  upon.    With  the  patient's  assistance,  pulling  upward 


FISSURE   IX  AXO 


501 


•upon  the  right  buttock,  while  the  surgeon  pnlls  downward  upon  the  left, 
the  anus  may  generally  be  everted  sufficiently  to  see  any  typical  fissure 
or  intra-anal  ulceration.  In  women  this  may  be  facilitated  by  the  in- 
troduction of  the  fingers  into  the  vagina,  and  pressing  backward  and 
downward,  so  as  to  evert  the  rectum  (Fig.  107).  These  maneuvers  always 
occasion  more  or  less  pain  in  true  fissure.  Sometimes  it  will  be  so  great 
that  the  patient  can  hardly  stand  an  examination  of  this  kind.  The 
introduction  of  a  small  Cjuantity  of  cocaine  upon  a  pledget  of  cotton 
will  occasionally  relieve  this  pain,  and  enable  one  to  examine  the  fissure 
without  great  disturbance.  As  a  rule,  however,  cocaine  is  very  poorly  ab- 
sorbed by  granu- 
lating surfaces, 
and  is  often  dis- 
appointing in 
these  examina- 
tions. If  the  2Da- 
tient  can  be  in- 
duced to  strain, 
fissures  between 
the  radial  folds 
can  generally  be 
brought  into 
comparatively 
good  view.  Fre- 
C|uently,  how- 
ever, this  effort 
brings  on  the 
t^i^ical  pain  of 
fissure,  and  he 
will    be    unable 

to  continue  it.  Under  such  circumstances^  if  one  keeps  at  hand  an 
insufflating  apparatus  containing  finely  powdered  ansesthesine,  and  will 
blow  on  the  fissured  surface  a  small  ciuantity  of  this  drug,  he  will 
be  able  after  a  few  moments  to  examine  the  parts  in  an  almost 
painless  manner.  Occasionally  this  drug  fails,  but  in  many  instances 
it  affords  great  relief  in  the  examination  of  ulcerating  conditions  of 
the  anus. 

Having  thus  seen  what  is  possible  upon  the  outside  and  lower  por- 
tion of  the  anal  canal,  digital  examination  should  be  made  to  deter- 
mine not  only  the  existence  of  a  fissure,  but,  if  possible,  its  cause.  The 
elevated  and  thickened  edges,  the  indurated  base,  or  the  smooth,  soft, 
circular  ulcer  just  above  the  margin  of  the  external  sphincter,  are  easily 
recognized  by  the  educated  touch.       Allingham  states  that  at  the  upper 


Fig.  107. — Etersiox  of  A^tteeiok  Fissup.e  by  Fixger  in  the 
Tagdta. 


302  THE   ANUS,   RECTUM,  AND   PELVIC   COLON 

end  of  an  anal  fissure  one  often  finds  clavate  papillte  or  small  polypoid 
growths  which  fall  into  the  cleft,  and  thus  prevent  healing.  He  states 
that  these  growths  are  not  the  cause  of  fissure  as  a  rule,  but  that  they 
certainly  keep  the  wound  open  and  prevent  its  healing.  His  further 
statement,  however,  that  when  such  growths  are  found  it  is  not  neces- 
sary to  examine  the  rectum  any  further  invites  criticism.  Assuming 
that  he  is  right  in  his  statement  that  these  little  neoplasms  are  not  the 
cause  of  fissure,  their  discovery,  therefore,  will  not  have  solved  the 
etiological  problem.  One  should  not  stop  at  this  point,  but  carry  his 
examination  farther,  and  determine  if  possible  whether  there  be  any 
pathological  or  anatomical  condition  above  this  which  will  account  for 
the  ulceration. 

In  the  introduction  of  the  finger  for  the  examination  of  fissure,  it 
should  always  be  pressed  to  the  opposite  segment  of  the  anus  from  that 
at  which  one  supposed  the  lesion  to  exist.  Thus  if  the  patient  com- 
plains of  pain  in  the  posterior  segment,  the  finger  should  be  carefully 
pressed  forward  and  introduced  to  its  full  length.  The  rectum  should 
then  be  examined  for  any  abnormalities,  and  the  anus  can  be  searched 
for  ulceration  as  the  finger  is  withdrawn.  With  the  use  of  ansesthesine 
and  these  precautions  very  little  pain  is  occasioned  by  such  examinations. 
The  ulcerations  are  largely  within  view  by  the  separation  of  the  radial 
folds,  and,  moreover,  they  can  be  so  clearly  and  distinctly  felt  that  their 
diagnosis  is  always  certain.  The  small  round  ulcer  of  the  anus  is  not 
so  easily  made  out,  and  the  speculum  is  of  advantage  to  diagnose  this 
condition. 

The  best  instrument  for  the  examination  of  these  ulcers  is  the  con- 
ical fenestrated  speculum  (Fig.  63).  The  segment  of  the  anus  in  which 
the  ulceration  exists  having  been  located  by  digital  examination,  the 
speculum  should  be  introduced  with  one  of  the  slides  opposite  this  area. 
Where  the  sphincter  is  tense  and  hard,  the  smaller  sized  speculum  should 
be  used.  After  the  instrument  has  been  introduced  to  its  full  extent 
the  slide  should  be  withdrawn  and  the  ulceration  can  then  be  clearly 
seen.  The  Sims's  vaginal  speculum  is  also  very  useful  in  these  cases. 
The  tubular  specula  and  the  anoscope  are  not  useful  in  the  examination 
of  these  conditions,  inasmuch  as  they  are  very  likely  to  slip  out  and 
give  the  patient  a  great  deal  of  pain  just  as  the  ulcers  come  into  view. 
Moreover,  the  conical  speculum  enables  us  to  treat  these  ulcerations 
locally  through  the  fenestra,  the  rest  of  the  circumference  of  the  anus 
being  thoroughly  protected  from  any  applications  which  one  may  make. 

Treatment. — The  treatment  of  anal  fissure  is  ordinarily  described 
as  palliative  and  curative.  There  is  no  place  in  rectal  surgery  for  the 
palliative  treatment  of  fissure.  Opiates  and  sedatives  which  relieve  the 
pain  always  increase  the  constipation  and  make  the  faecal  passages  not 


FISSURE  IX  AXO  303 

only  more  painful  but  more  injurious  to  the  diseased  condition.  The 
treatment  therefore  resolves  itself  into  the  non-operative  and  operative 
methods.  The  first  step  consists  in  removing  the  cause  if  possible.  For 
those  cases  due  to  constitutional  syphilis,  the  line  of  treatment  is  laid 
down  in  the  chapter  upon  Venereal  Diseases. 

In  those  cases  in  which  a  polypus  or  papilloma  complicates  the 
fissure  it  is  useless  to  attempt  local  treatment  without  the  removal  of 
these  neoplasms.  Where  it  is  due  to  constipation  and  atrophic  catarrh, 
these  should  be  treated  along  with  the  fissure,  as  the  latter  is  sure  to 
recur  if  these  conditions  persist. 

The  regulation  of  the  bowels  is  of  the  utmost  importance  in  chil- 
dren as  well  as  in  adults.  When  the  movements  are  regular,  but  the 
fsecal  mass  is  hard  and  lumpy,  an  injection  of  a  small  quantity  of  sweet- 
oil  and  glycerin  during  the  morning  hours  will  generally  afford  great 
relief.  This  may  be  injected  through  a  small  syringe  at  a  time  some- 
what previous  to  the  usual  period  of  defecation.  One  smooth,  regular 
passage  a  day  is  better  than  an  occasional  purging.  Allingham  recom- 
mends for  this  purpose  the  use  of  figs  soaked  in  sweet-oil,  or  onions  and 
milk  at  bedtime.  The  use  of  figs  as  a  laxative  in  rectal  diseases  is 
objectionable  from  the  fact  that  the  small  seeds  are  not  digested  in  the 
intestinal  canal,  and  are  likely  to  lodge  in  the  ulcerated  areas  and  cause 
irritation.  Phosphate  of  soda  given  in  the  morning  is  sometimes  effec- 
tual in  the  production  of  such  fgecal  passages.  Saline  laxatives,  sulphate 
of  magnesia,  sulphate  of  soda,  etc.,  and  the  cathartic  waters,  such  as 
Hunyadi,  Friedrichshall,  Apenta,  and  Eubinat,  are  more  likely  to  pro- 
duce frequent  thin,  liquid  passages,  which  are  irritating.  Cascara  with 
malt  is  quite  satisfactory,  but  one  must  experiment  with  every  patient 
to  determine  the  amount  necessary.  The  resinous  cathartics,  such  as 
gamboge,  podoph3dlin,  aloes,  etc.,  are  all  irritating  to  a  fissured  anus. 
Cripps  thinks  highly  of  a  confection  of  black  pepper  and  senna  in  equal 
parts,  and  recommends  two  large  teaspoonfuls  of  this  for  an  adult  upon 
rising  in  the  morning. 

The  diet  should  be  carefully  controlled,  and  if  possible  the  bowels 
should  be  regulated  by  this  means  rather  than  by  medicine.  If  there 
are  haemorrhoids,  a  cold  enema  in  the  morning  will  relieve  the  conges- 
tion in  these,  and  ordinarily  produce  a  satisfactory  movement  of  the 
bowels. 

Non-operative  Treatment. — Where  the  fissure  is  acute  and  there  is  no 
marked  induration  of  its  base,  it  may  be  cured  without  any  operative 
interference.  The  patient's  constitutional  condition  should  be  built  up, 
and  as  much  rest  in  the  recumbent  posture  as  possible  should  be  en- 
joined. Experience  teaches  that  Jying  down  innnediately  after  fascal 
movements  prevents  in  a  large  measure  the  pains  of  fissure.     If  there- 


304  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

fore  a  patient's  occupation  prevents  him  from  obtaining  such  rest  during 
the  morning  hours,  it  is  wise  for  him  to  regulate  his  bowels  to  move 
at  an  evening  hour,  so  that  he  can  go  to  bed  and  remain  quiet  afterward. 

The  injection  of  solutions  such  as  starch-water  and  opium,  iodoform 
and  oil,  and  lead-water  and  laudanum  after  faecal  passages  appears  irra- 
tional and  productive  of  no  good ;  the  only  possible  relief  which  they 
can  afford  to  the  fissure  is  through  absorption,  and  their  effect  upon  the 
nervous  system;  they  do  not  come  in  contact  with  the  ulcer,  and  add 
more  irritation  through  the  introduction  of  the  syringe-tip  necessary 
for  their  administration.  If  such  remedies  are  necessary  it  would  be 
better  to  administer  the  opiate  hypodermically  or  by  the  mouth. 

Cripps  recommends  an  ointment  composed  of  ferri  subsulphate,  10 
grains,  and  unguentum  petrolii,  1  ounce.  In  some  patients  this  ointment 
gives  pain,  in  others  he  says  it  is  very  beneficial.  He  also  recommends 
the  application  of  a  small  amount  of  the  following  ointment  to  the 
fissured  spot  a  few  moments  before  the  fsecal  movement,  and  again 
after  it  has  passed : 

!^  Ext.  conii oij ; 

Olei  ricini oiij ; 

Ung.  lanolinii ^ij. 

Allingham  states  that  there  is  nothing  better  as  a  local  application 
than  the  following  ointment : 

I^   Hyd.  subchlor gr.  iv ; 

Pulv.  opii gr.  ij ; 

Ext.  belladonna?   gr.  ij ; 

Ung.  sambuci 5j. 

M. 

Ointments  containing  cocaine,  bismuth,  iodoform,  aristol,  resinol, 
etc.,  and  sometimes  a  certain  amount  of  morphine,  have  been  highly 
recommended  by  various  authorities.  As  a  rule,  however,  they  are  not 
of  much  benefit,  save  the  ointment  of  conium,  recommended  by  Cripps. 
Recently,  however,  the  author's  treatment  of  fissure  in  ano  has  entirely 
changed  so  far  as  local  applications  are  concerned.  It  is  no  longer  a 
question  as  to  the  length  of  time  a  fissure  has  existed,  whether  it  is 
curable  by  local  treatment  or  not ;  the  condition  of  the  sphincter  and 
the  amount  of  induration,  together  with  the  depth  to  which  the  ulcera- 
tion has  extended,  are  the  important  factors.  If  the  sphincter  is  hyper- 
trophied,  hard,  and  spasmodically  contracted,  if  the  ulcer  is  deep  and 
indurated  at  its  base,  with  its  edges  thickened  and  the  sentinel  pile  well 
developed,  one  can  not  generally  succeed  in  curing  the  condition  without 
some  operative  interference.     Especially  is  this  true  if  the  muscular 


FISSURE  IN  ANO  305 

fibers  are  exposed  and  can  be  clearly  seen  by  the  use  of  a  magnifying 
glass.  Where,  however,  these  conditions  do  not  exist  one  may  confi- 
dently predict  a  cure  without  any  operation.  The  treatment  consists  in 
the  application,  first,  of  small  quantities  of  ansesthesine  insufflated  on  the 
surface  of  the  ulcer;  after  a  few  minutes  a  pledget  of  cotton  soaked  in 
pure  ichthyol  is  applied;  these  applications  are  made  through  the  coni- 
cal speculum,  as  was  described  above.  The  treatment  is  carried  out  every 
other  da}^,  together  with  the  regulation  of  the  bowels.  The  introduc- 
tion of  the  speculum  serves  to  gradually  dilate  the  sphincter  and  takes 
the  place  of  bougies.  It  is  now  some  five  years  since  this  treatment  was 
commenced,  and  during  that  time  not  more  than  10  cases  of  uncompli- 
cated fissure  have  been  seen,  which  could  not  be  cured  without  operative 
interference.  In  the  beginning  of  this  method  of  treatment  anaesthesine 
was  not  known,  and  solutions  of  cocaine  were  used  to  relieve  the  pain. 
Sometimes  this  was  efficient  and  sometimes  not.  In  those  cases  in 
which  cocaine  was  ineffectual  the  patient  suffered  considerable  pain 
after  the  first  two  or  three  treatments,  but  it  gradually  grew  less  and 
less  at  each  succeeding  one  until  the  ulcer  entirely  healed.  In  the  mean- 
time, however,  the  fseeal  passages  always  became  less  painful  after  the 
first  application,  and  the  patients  have  always  been  willing  to  bear  the 
pain  of  the  application  rather  than  to  submit  to  the  knife.  When  there 
has  been  much  spasm  of  the  sphincter  the  parts  may  be  smeared  with 
an  ointment  composed  of 

I^     Ung.  stramonii,    ^ 

Ung.  belladonnse,  I aa  3iv. 

Ung.  hyoscyami,  j 
M. 

This  always  seemed  to  relieve  the  spasm  and  control  in  a  large  meas- 
ure the  pain  that  resulted  from  the  application  of  the  ichthyol.  After 
the  use  of  anaesthesine  this  ointment  is  rarely  necessary.  Whenever  a 
hypertrophy  of  the  sentinel  pile  exists  or  there  are  little  teats,  they 
should  be  cocainized  and  snipped  off  with  scissors. 

The  average  length  of  time  consumed  in  the  treatment  of  fissures 
l)y  this  method  has  been  something  less  than  four  weeks,  but  in  the 
majority  of  acute  cases  relief  is  obtained  in  ten  days  to  a  fortnight.  In 
a  large  number  of  cases  three  or  four  applications  of  the  ichthyol  have 
resulted  in  a  complete  cure.  Where  the  treatment  is  not  successful 
within  four  weeks  it  is  advisable  that  the  patients  submit  to  operative 
interference.  At  the  same  time,  where  the  condition  is  complicated  by 
haemorrhoids  or  neoplasms  of  the  rectum,  such  as  polypi,  adenomata,  or 
papillomata,  local  treatment  will  be  of  little  avail,  and  the  method  will 
be  brought  into  disrepute  by  its  application  in  such  cases.  Operative 
20 


306  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

treatment  should  therefore  be  resorted  to  at  once  under  these  condi- 
tions. 

The  author's  experience  entirely  agrees  with  the  statement  of  Ailing- 
ham,  that  lateral  and  anterior  fissures  can  always  be  healed  without 
operative  interference ;  but  that  fissure,  with  induration  and  hypertrophy 
of  the  sphincter,  is  always  sure  to  recur  when  healed  in  this  manner. 

Mtrate  of  silver  in  solutions  of  from  2  to  50  per  cent,  and  some- 
times in  the  solid  stick,  is  a  useful  remedy.  It  stimulates  sluggish 
ulcers,  destroys  exuberant  granulations,  and  forms  a  coating  of  albu- 
minoid of  silver  over  the  lesion,  which  protects  it  from  irritation  by  the 
faeces.  Occasionally  it  relieves  the  pain  after  one  or  two  applications, 
and  accomplishes  rapid  healing.  This,  however,  only  occurs  in  shallow, 
uncomplicated  fissures.  The  other  chemical  cauterants  are  not  so  good. 
Painting  the  ulcer  over  with  iodoform,  10  per  cent,  and  flexible  collodion, 
90  per  cent,  will  sometimes  give  great  relief.  The  parts  should  always 
be  held  apart  until  the  ether  in  the  collodion  thoroughly  evaporates, 
otherwise  it  M'ill  give  great  pain  and  blister  the  surrounding  parts. 
Eecent  experiences  indicate  that  a  25-  to  50-per-cent  solution  of  argyrol 
will  prove  one  of  our  best  local  remedies  in  fissure.  The  treatment  by 
ichthyol,  however,  is  the  most  satisfactory. 

Operative  Treatment. — The  operative  methods  for  the  treatment  of 
fissure  comprise  dilatation,  incision,  and  excision.  Incision  and  excision 
are  probably  both  older  methods  than  dilatation,  and  yet  perhaps  at  the 
present  day  the  large  majority  of  fissures  are  treated  by  forcible  dila- 
tation. This  method  is  usually  credited  to  Eecamier,  but  upon  investiga- 
tion it  was  found  that  his  method  was  not  that  of  forcible  dilatation  at 
all,  but  rather,  as  he  calls  it,  a  "  massage  cadence."  It  consisted  in 
introducing  the  fingers  into  the  anus  and  grasping  the  sphincter  muscle 
with  the  thumb  outside,  and  in  this  manner  carrying  on  a  massage  all 
around  the  sphincter  until,  as  he  claims,  it  became  softened  and  less 
spasmodic.  The  results  of  this  method  are  not  clearly  laid  down  in 
literature,  but  shortly  thereafter  Maisonneuve  (Clinical  Chirg.,  t.  ii, 
186-i)  advised  and  practised  forcible  dilatation.  His  method  consisted 
in  introducing  one  finger  after  another  into  the  anus  until  the  whole 
palm  of  the  hand  passed  through  the  sphincters,  then  doubling  the  fin- 
gers up  he  further  distended  the  parts  with  his  fist  until  complete  re- 
laxation of  the  sphincter  was  obtained.  At  the  time  of  Maisonneuve's 
operation  angesthesia  was  little  known,  and  such  a  method  was  not  likely 
to  become  popular  on  account  of  the  extreme  pain  it  produced  compared 
with  the  simple  operation  of  incision  which  Boyer  had  introduced  many 
years  before. 

The  other  method  of  dilating  the  sphincter,  as  has  been  described  in 
the  chapter  on  Hcemorrhoids,  consisted  in  introducing  the  thumb  of  each 


FISSURE  IN  ANO  307 

hand  through  the  anus,  and  with  the  fingers  upon  the  tuberosities  of  the 
ischii,  dihiting  the  sphincter  thoroughly  from  side  to  side,  and  then  with 
the  fingers  upon  the  pubis  and  coccyx  gently  stretching  it  antero- 
posteriorly.  This  procedure  should  be  done  slowly  and  gradually  for 
four  or  five  minutes,  stretching  the  parts  in  all  directions  until 
the  muscle  becomes  so  flaccid  and  loose  that  there  is  little  tendency  to 
recontract. 

There  have  been  a  good  many  theories  advanced  with  regard  to  the 
process  by  which  dilatation  relieves  the  pain  of  a  fissure.  Some  hold 
that  it  is  entirely  due  to  overcoming  the  spasm  of  the  sphincter,  arguing 
that  the  sufliering  which  patients  endure  is  caused  not  by  the  ulcer  itself 
but  by  the  muscular  contractions  which  squeeze  and  irritate  the  exposed 
nerves.  Others  hold  that  the  relief  is  occasioned  by  the  stretching  of 
the  nerves,  and  is  comparable  to  that  which  is  seen  to  follow  stretching 
the  nerve  in  cases  of  sciatica.  Still  others  hold  that  the  relief  is  occa- 
sioned by  the  subcutaneous  and  superficial  haemorrhage  in  such  cases 
acting  as  a  depleting,  antiphlogistic  agent  to  the  local  congestion.  Ee- 
cent  experimental  studies  in  this  line  seem  to  indicate  that  it  may  pos- 
sibly be  due  to  the  reflex  effect  upon  the  spinal  center  due  to  temporary 
traumatism  of  the  nerve-ends.  What  is  exactly  accomplished  by 
stretching  is  not  clearly  understood.  Experiments  recorded  by  Ailing- 
ham,  and  repeated  upon  dogs  by  Hartmann,  demonstrate  that  by  stretch- 
ing, the  muscular  fibers  are  not  broken  nor  are  their  fibrous  attachments 
anteriorly  or  posteriorly  severed.  There  are  no  haemorrhages  in  the 
muscular  tissue  itself,  and  there  appear  to  be  no  alterations  in  the  nerve- 
ends.  The  base  of  the  ulcer  is  deepened,  but  it  is  impossible  to  sup- 
pose that  by  this  means  alone  a  healthy  ulcer  can  be  established;  if,  in 
short,  the  ulceration  is  due  to  infection  of  a  traumatic  lesion,  this  infec- 
tion will  still  be  operative  after,  as  it  was  before  the  stretching.  The 
operation  can  not  change  the  nature  of  the  ulcer.  Hartmann's  conclu- 
sions are  that  the  relief  obtained  by  forcible  dilatation  is  due  to  the 
production  of  "  a  reflex  atony  of  the  sphincters."  The  fact  that  the 
muscles  soon  regain  their  tonicity  is  opposed  to  this  view.  It  appears 
more  probable  that  the  relief  is  due  to  the  fact  that  by  the  forcible 
stretching,  the  nerves  which  are  caught  and  held  by  inflammatory 
processes  are  torn  loose  from  these  attachments,  released  from  their 
embrace,  and  also  from  the  squeezing  consequent  upon  sphincteric 
contraction.  This,  like  all  the  other  theories,  is  purely  hypothetical. 
The  fact  that  incision  relieves  the  pain  quite  as  promptly  would  indicate 
that  the  effect  was  due  to  disabling  the  sphincter  temporarily. 

Some  surgeons  dilate  the  sphincter  with  divulsors,  such  as  those  of 
Sims,  Thebaud,  and  Worbe — that  of  Mathews  is  one  of  the  best.  In 
cases  in  which  there  is  a  very  strong  sphincter  a  Van  Buren  or  Sims's 


308  THE  ANUS,   RECTUM,  AND   PELVIC   COLON 

vaginal  speculum  will  be  found  to  be  helpful,  but  instruments  are  rarely 
necessary  in  this  operation. 

In  the  face  of  the  preponderance  of  testimony  as  to  the  curative 
effect  of  forcible  dilatation  in  fissure,  the  author  is  compelled  to  state 
that  his  experience  does  not  corroborate  the  opinions  of  the  majority 
of  writers  upon  this  subject;  he  has  not  only  had  it  fail  in  his  own 
operations,  but  he  has  seen  a  large  number  in  whom  the  operation 
had  been  practised  by  other  surgeons  without  success ;  at  least  the  fissure 
returned  within  a  short  time  afterward.  It  is  needless  to  say  that  in 
those  cases  where  there  is  a  polypus  at  the  upper  angle  of  the  fissure, 
stretching  alone  will  not  cure  the  condition.  It  is  necessary  to  remove 
the  complicating  tumor.  Sometimes  it  is  overlooked,  and  this  explains 
the  failure.  The  same  may  also  be  said  of  sentinel  piles  at  the  lower 
angle  of  the  wound.  But  laying  these  cases  aside  in  which  the  opera- 
tion may  be  said  to  have  been  incompletely  done,  there  are  still  others, 
especially  at  the  posterior  commissure,  in  which  stretching  does  not 
result  in  a  cure.  Where  there  is  considerable  induration  and  hyper- 
trophy of  the  edges  of  the  ulcer,  stretching,  while  it  relieves  the  pain 
for  the  time  being,  will  not  result  in  a  permanent  cure,  owing  to  two 
facts :  First,  these  hypertrophied  edges  fold  inward  and  interfere  with 
healing;  second,  the  fissure  is  practically  seated  upon  fibrous  tissue  at 
the  juncture  of  the  muscular  fibers  as  they  come  together  to  form  a 
sort  of  tendon  behind  the  anvis,  and  these  fibers  are  simply  separated 
by  the  stretching  and  not  torn  or  paralyzed.  The  result  is  that  the 
infolding  edges  prevent  rapid  healing,  and  the  muscles,  speedily  regain- 
ing their  power,  reproduce  all  the  old  symptoms. 

In  such  conditions  the  edges  should  be  trimmed  off  and  the  muscle 
incised,  as  will  be  described  presently.  There  is  a  difference  among 
writers  with  regard  to  the  class  of  cases  in  which  dilatation  should  be 
practised.  Allingham  states  that  it  is  the  safest  method  in  old  people, 
and  in  tuberculous  and  vitiated  constitutions.  Mathews,  on  the  other 
hand,  states  that  the  operation  should  be  avoided  in  such  cases.  To 
one  who  has  had  very  much  experience  in  operations  upon  old  people  two 
facts  are  prominent :  the  first  is,  that  these  individuals  do  not  recover 
muscular  tonicity  with  any  degree  of  certainty;  the  other  is  that  they 
all  bear  suppurative  diseases  very  poorly,  whereas  in  aseptic  conditions 
their  tissues  unite  in  a  most  satisfactory  manner  (Tuttle,  Operations  on 
the  Aged,  Journal  of  the  American  Medical  Association,  vol.  i,  1901). 
With  these  facts  in  view  one  can  realize  that  the  operation  of  divulsion 
may  easily  result  in  incontinence  in  these  individuals.  On  the  other 
hand,  incision  may  cause  suppuration  and  death  from  exhaustion.  It 
will  be  better  in  such  cases  to  adopt  a  method  by  which  both  of  these 
dangers  can  generally  be  avoided — i.  e.,  excision  with  immediate  suture. 


FISSURE  IN  ANO  309 

In  cases  of  phthisis  the  fissure  is  very  likely  to  be  tubercular  in  its 
nature,  and  incision  and  stretching  are  both  undesirable.  If  the  lesion 
can  be  thoroughly  excised,  and  the  edges  sewed  together,  it  is  perfectly 
proper  to  do  so.  If  not,  these  wounds  had  better  be  treated  by  the  actual 
cautery  or  by  local  applications.  Where  the  fissures  are  multiple,  forci- 
ble dilatation  is  always  advisable ;  and  in  children  who  do  not  bear  local 
treatment  patiently,  this  method  is  exceedingly  successful,  except  in 
those  due  to  syphilitic  disease. 

Results  of  Dilatation. — At  the  time  of  dilatation  there  is  always  some 
hemorrhage,  but  it  is  never  alarming.  If  carefully  and  slowly  done 
there  will  be  very  little  tearing  or  traumatism  of  the  parts;  there  is 
always  an  extravasation  of  blood  into  the  cellular  tissue  around  the  anus 
and  a  consequent  discoloration  and  congestion  for  a  few  days  following. 
Experiments  have  shown  that  there  is  no  extravasation  of  blood  in  the 
muscle,  no  rupture  of  its  fibers,  and  no  laceration  of  the  fibrous  rhaphe 
(Quenu  and  Hartmann,  p.  444).  The  length  of  time  during  which  the 
paralysis  of  the  muscles  lasts  is  variable.  If  one  will  examine  the 
anus  of  a  healthy  adult  patient  after  it  has  been  divulsed,  he  will  find 
that  within  an  hour  following  the  operation  there  is  no  longer  any  gap- 
ing, and  stimulation  to  the  muscle  will  produce  a  certain  amount  of 
contraction.  This  contraction  continues  to  increase  until  within 
twenty-four  to  forty-eight  hours  the  patient  will  have  regained  con- 
siderable sphincteric  control,  and  at  the  end  of  seventy-two  hours  ordi- 
narily, complete  sphincteric  action  will  have  returned.  Even  within  a 
few  hours  spasmodic  twitching  is  resumed  in  most  eases.  The  idea  that 
the  sphincter  remains  paralyzed  for  a  sufficient  time  for  the  ulcer  to 
heal  is  not  borne  out  by  facts. 

If  the  healing  of  the  fissure  depends  upon  the  maintenance  for  a 
certain  length  of  time  of  the  paralysis  of  the  sphincteric  contractions, 
the  question  arises  whether  it  is  not  wise  to  introduce  into  the  rectum 
either  a  firm  plug  or  bougie,  and  maintain  it  there  for  a  few  days,  so 
that  by  long-continued  stretching  this  paralysis  will  remain  more  per- 
manent. This  method  is  employed  by  many  surgeons  after  operations  on 
haemorrhoids,  and  the  author  has  used  it  with  good  effect  in  fissure.  The 
Pennington  tubes  serve  excellently  for  this  purpose;  by  wrapping  with 
gauze  the  plug  can  be  made  any  size,  and  the  rubber  covering  prevents 
the  granulations  becoming  caught  in  the  meshes,  and  thus  torn  when 
it  is  taken  away.  The  tube  is  best  introduced  through  a  bivalve  specu- 
lum, and  held  in  position  by  a  safety-pin  attached  to  a  J-bandage.  By 
this  means  the  dilatation  of  the  sphincters  is  maintained,  and,  strange 
to  say,  after  forty-eight  hours  the  patient  feels  more  comfortable  with 
the  plug  in  place  than  he  does  with  it  out. 

Unquestionably  this  prolonged  dilatation  hastens  recovery  and  makes 


310  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

the  faecal  passages  at  first  much  easier.  It  is  advisable  in  any  case  of 
severe  fissure  operated  upon  by  the  method  of  dilatation.  Permanent 
incontinence  has  been  seen  to  follow  divulsiou  of  the  anus,  and  a  loss 
of  sensation  that  indicates  the  approach  of  fscal  or  gaseous  passages  is 
not  at  all  infrequent.  The  author  has  had  tvro  patients  in  whom  this 
operation  has  been  followed  by  unconscious  stools  at  night,  requiring 
them  alwaAs  to  wear  a  napkin. 

Method  of  Incision. — The  second  method  of  operating  in  anal  fissure 
consists  in  an  incision  through  the  base  of  the  ulcer.  This  method 
was  first  advocated  by  Boyer  in  1788,  and  since  that  time  has  been 
described  under  his  name.  Boyer,  holding  that  the  fissure  was  due 
to  spasm  of  the  sphincter,  advised  complete  section  of  that  muscle  in 
order  to  absolutely  control  this  spasmodic  contraction.  So  far  as  can 
be  learned,  he  did  not  advocate  cutting  through  the  base  of  the  ulcer 
at  all,  but  even  sometimes  made  a  section  of  the  muscle  upon  either 
side  of  the  rectum,  thus  completeh'  parah'zing  it.  The  fact  that  these 
operations,  which  did  not  affect  the  ulcer  per  se,  resulted  in  immediate 
relief  of  the  painful  s^Tiiptoms,  and  a  cure  of  the  fissure  lends  color 
to  his  theory.  He  also  introduced  a  hard  bougie  surrounded  with 
charpie,  and  thus  kept  up  continuous  dilatation.  Following  him,  others 
thought  that  it  was  not  necessar}-  to  incise  so  deeply,  holding  that  it 
was  only  the  superficial  fibers  that  kept  up  motion  in  the  ulcerated 
surface  and  thus  prevented  healing. 

Mathews,  even  as  late  as  1895,  advocated  scarifying  the  fissure  with 
the  edge  of  a  knife  instead  of  cutting  the  muscular  fibers,  and  claimed 
that  he  obtained  just  as  good  results.  Among  those  who  believed  in 
the  superficial  incision  may  be  mentioned  the  celebrated  Dupm-tren, 
Curling,  and  Copeland.  The  latter  even  held  that  an  incision  into 
the  mucous  membrane  alone  was  sufficient  to  cure  a  fissure.  But  un- 
fortunately the  majority  of  these  ulcers  has  already  passed  beyond  the 
depth  of  the  mucous  membrane  and  invaded  the  submucous  tissue, 
sometimes  even  the  muscular  fibers,  and  therefore  this  operation  will 
not  suffice. 

The  depth  of  the  incision  and  the  point  at  which  it  should  be  made 
are  of  the  utmost  importance.  It  should  be  deep  enough  to  put  the 
muscle  thoroughly  at  rest.  It  should  also  be  made  through  the  ulcer, 
for  otherwise  it  would  produce  a  site  for  infection  and  possibly  a  second 
fissure.  This  applies  to  ulcers  which  are  not  directly  in  the  anterior 
or  posterior  commissure.  In  these  cases  it  is  only  necessary  to  refer 
for  a  moment  to  the  anatomy  of  the  region  to  see  that  an  incision 
directly  in  the  posterior  commissure  would  not  sever  the  muscle.  The 
fibers  of  the  external  sphincter  unite  in  a  sort  of  tendinous  prolonga- 
tion at  the  posterior  commissure.     The}'  do  not  decussate  to  any  marked 


FISSURE  IN  ANO 


311 


Fig.  108.— V-shaped  Incision  foe  Fis- 
slee  at  the  posterior  colqiissuke 

OF  THE  Anus. 


degree,  but  joroceed  parallel  with  each,  other  back  to  their  insertion  in 
the  coccyx.  An  incision  therefore  directly  back  to  the  tip  of  the 
coccyx  will  result  in  the  separation  of  most  of  these  fibers  and  the 
cutting  of  very  few.  This  Avill  not  put  at  rest  the  muscular  contrac- 
tion, and  therefore  it  will  fail  in  fissure 
directly  in  the  posterior  commissure. 
Moreover,  those  fibers  which  are  severed 
by  the  incision  will  be  cut  at  an  oblique 
angle,  which  is  alwa3^s  slow  to  heal  and 
forms  an  irregular  cicatrix  which  is  not 
conducive  to  the  best  functional  action, 
of  the  muscle.  Thus  it  will  be  seen  why 
in  these  cases  oj^erations  by  divulsion 
and  incision  have  both  failed.  In  the 
one  the  muscular  fibers  are  disabled  for 
a  short  time  and  separated  by  the  force 
of  stretching,  in  the  other  the  fibers  are 
simply  separated  by  the  edge  of  a  sharp 
knife,  which  may  cut  a  few,  but  by  no 
means  enough  to  paralyze  the  action  of 

the  muscle.  The  experiments  of  Quenu  and  the  other  Parisian  surgeon, 
whom  Allingham  quotes  but  does  not  give  his  name,  are  very  important 
with  regard  to  the  observations  upon  this  point.  They  say  that  there  is 
no  rupture  of  the  muscular  fibers  nor  of  the  tendinous  fibers.  There- 
fore their  contractility  returns  very  soon. 

All  this  digression  derives  its  importance  from  the  fact  that  it  ex- 
plains the  failure  of  the  conmionly  accepted  methods  in  the  treatment 
of  a  great  many  cases  of  fissure.  Those  at  the  commissures  should  be 
treated  by  incision,  and  this  should  be  made  on  one  side  or  the  other 
in  order  to  sever  the  muscles  and  put  them  at  rest.  The  V-shaped 
incision  (Fig.  108)  serves  excellently  in  these  cases,  because  it  puts  at 
rest  the  fibers  of  both  sides  over  which  the  ulcer  is  situated.  It  also 
cuts  them  squarely  across,  thus  conducing  to  a  small  cicatrix.  By 
this  incision  many  cases  can  be  promptly  cured  which  are  rebellious 
to  the  ordinary  cuts  and  to  divulsion.  It  succeeded  in  one  case  in 
which  these  methods  had  been  tried  five  times  and  failed. 

Length  and  Depth  of  Incision.— The  length  of  the  incision  should 
be  a  little  greater  than  the  ulceration,  starting  above  it  and  ending 
slightly  below  it.  The  depth  of  the  incision  should  extend  about  a 
quarter  of  an  inch  deeper  than  the  deepest  portion  of  the  ulcer.  These 
are  the  only  safe  guides. 

As  Allingham  points  out,  there  is  much  more  danger  of  failing  to 
cure  a  fissure  by  too  superficial  incision  than  there  is  of  incontinence 


312  THE  ANUS,  RECTUM,  AND  PELVIC  COLON. 

from  a  single  deep  incision  at  right  angles  through  the  sphincter  mus- 
cles. He  says  that  if  the  incision  is  made  squarely  across  the  mus- 
cular fibers  the  ulceration  will  heal  before  these  reunite,  and  when  the 
union  has  been  completed  there  will  be  a  thin  square  cicatrix  which 
will  not  interfere  with  the  functional  action  of  the  muscle.  If  the 
incision  be  made  at  an  angle  the  fibers  will  not  entirely  separate,  they 
will  unite  too  soon,  and  there  will  be  a  long,  irregular  cicatrix  and 
permanent  lengthening  and  loss  of  power  in  the  muscle. 

It  is  therefore  better  to  carry  the  incision  a  little  too  deep  than  to 
take  any  chances  of  failure  to  cure  the  j^atient  by  too  great  a  con- 
servatism. A  slight  superficial  cut  will  relieve  the  pain  temporarily, 
but  it  does  not  paralyze  the  sphincter  for  a  sufficient  time  for  it  to 
result  in  the  healing  of  the  ulcer  and  a  cure  of  the  fissure.  If,  how- 
ever, the  incision  is  deep  enough  to  thoroughly  divide  the  muscular 
fibers,  they  will  retract  and  the  ulcer  will  have  abundant  opportunity 
to  heal  before  a  sufficiently  firm  cicatrix  has  formed  to  enable  the 
muscle  to  act. 

The  theory  upon  which  this  practice  rests  in  cases  of  great  hyper- 
trophy of  the  sphincter  muscle  is  that  this  section  and  retraction  of 
the  muscular  fibers  put  them  absolutely  at  rest  until  the  cicatricial 
union  between  their  ends  gives  them  an  attachment  through  which 
they  can  exercise  their  powers.  At  the  same  time  this  cicatricial  inter- 
position lengthens  their  attachment  and  thus  decreases  their  contractile 
power.  Thus  a  temporarily  complete  rest  and  the  elongation  of  the 
fibers  through  this  interposition  of  the  cicatrix  brings  about  a  partial 
atrophy  of  the  muscle,  restoring  it,  comparatively  speaking,  to  its 
original  state. 

One  great  advantage  of  operation  by  the  knife  at  the  present  day 
consists  in  the  fact  that  general  anaesthesia  is  unnecessary.  In  divulsion 
it  is  almost  a  necessity,  but  l)y  the  hypodermic  injection  of  cocaine  or 
eucaine  it  is  possible  to  incise  any  case  of  fissure  absolutely  without 
pain  beyond  the  slight  prick  of  the  needle  for  the  introduction  of  the 
drug. 

The  strength  of  the  cocaine  solution  to  be  used  may  be  from  1  to 
4  per  cent.  The  infiltration  method  of  Schleich  is  not  only  painful 
but  uncertain,  especially  where  there  is  any  amount  of  inflammation 
and  infiltration  of  the  parts.  A  2-per-cent  solution  of  cocaine  or  a 
4-per-cent  solution  of  eucaine  is  upon  the  whole  the  most  satisfac- 
tory. Five  or  10  minims  of  the  cocaine  solution,  if  slowly  and  care- 
fully introduced,  will  anaesthetize  almost  any  anal  fissure  and  enable  us 
to  incise  the  muscle  and  scrape  out  the  fissure  without  any  pain.  It 
is  necessary  in  these  cases  to  use  the  finest  hypodermic  needle.  First, 
in  order  that  the  minimum  amount  of  pain  may  be  occasioned  by  its 


FISSUKE  IN  ANO  313 

introduction;  and  second_,  in  order  that  the  amount  of  the  fluid  used 
may  be  so  slowly  injected  that  it  will  disseminate  itself  over  a  large 
area.  Eeeent  experiments  with  medullary  anaesthesia  show  what  a 
powerful  influence  minute  quantities  of  a  weak  solution  have  when 
applied  directly  to  the  nerve-centers  or  to  the  nerve-tissues  themselves; 
so  that  in  these  operations  it  is  only  necessary  to  bring  the  smallest 
quantity  of  the  solution  into  contact  with  the  nerve-ends  or  the  nerve- 
trunks  in  order  to  completely  anaesthetize  the  parts.  The  best  prac- 
tice is  to  introduce  the  needle  through  the  healthy  skin  just  below  the 
fissure^,  and  by  this  one  puncture  to  carry  the  cocaine  beneath  and 
upon  each  side  of  it  in  order  to  bring  the  drug  in  contact  with  the  nerve- 
trunks  and  nerve-ends  supplying  the  diseased  area.  After  the  cocaine 
has  been  injected  for  two  or  three  minutes,  a  Sims  or  Van  Buren  specu- 
lum can  be  introduced  and  the  exact  location  and  the  extent  of  the 
ulcer  seen.  A  competent  rectal  surgeon  ought  to  be  able  to  tell  this 
by  digital  touch;  but  the  addition  of  the  sense  of  sight  and  the  accuracy 
with  which  work  can  be  done  which  is  clearly  in  view,  compared  with 
that  done  only  by  touch,  can  not  possibly  be  of  any  disadvantage  to  the 
most  expert  surgeon,  and  it  is  an  absolute  necessity  to  those  who  only 
operate  semioccasionally. 

If  there  be  any  proud  flesh  or  exuberant  granulations  in  the  ulcer 
they  should  be  scraped  out  with  a  sharp  curette  or  a  Volkmann  spoon. 
After  this  the  incision  should  be  packed  thoroughly  with  a  small  strip 
of  iodoform  or  sterilized  gauze  and  the  patient  kept  in  bed  for  forty- 
eight  hours.  This  injunction  with  regard  to  keeping  the  patient  in 
bed  makes  the  author  liable  to  the  charge  of  inconsistency  between 
practice  and  teaching  in  the  eyes  of  many  of  his  old  students,  for  they 
well  know  that  more  frequently  than  otherwise  he  operates  upon  these 
cases  of  fissure  in  his  clinic,  allows  them  to  get  up  and  walk  home  an 
hour  or  so  afterward,  and  to  resume  their  work  upon  the  following 
day.  Many  of  the  students  have  seen  case  after  case  return  at  the 
next  lecture  absolutely  free  from  pain  and  grateful  for  the  relief 
afforded  them.  Nevertheless,  in  private  practice,  it  is  not  wise  to  take 
the  chances  which  one  takes  in  clinical  work.  Many  of  these  patients 
in  the  clinic  depend  upon  their  daily  labor  for  food  and  support  for 
their  wives  and  children,  and  it  is  of  the  utmost  importance  that  they 
keep  about  in  order  to  retain  their  positions.  As  a  consequence  the 
majority  of  them  would  refuse  to  have  anything  whatever  done  which 
entailed  the  necessity  of  their  laying  up  from  work.  Thus  while  the 
operation  upon  walking  cases  is  not  a  method  of  choice,  it  is  justified 
by  the  necessities  of  the  case.  The  results  of  this  practice  are  sufficient 
answers  to  the  claims  of  French  surgeons  that  the  method  of  divulsiou 
requires  less  bodily  confinement  than  that  of  incision.     The  effect  of 


314  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

general  anfesthesia  itself  detains  a  laboring  man  from  his  work  longer 
than  a  whole  operation  by  incision.  Moreover,  the  latter  causes  no 
traumatism,  contusion,  or  extravasation  of  blood  into  the  cellular  tis- 
sues, as  does  forcible  dilatation. 

The  dangers  of  hgemorrhage  into  the  cellular  tissues  following  forci- 
ble dilatation  are  not  to  be  ignored,  as  will  be  seen  from  the  cases 
described  in  another  portion  of  this  work  (see  chapter  on  Haemorrhoids). 
It  is  needless  to  say  that  in  the  operation  by  incision  all  sentinel  piles, 
poh'pi,  papilla^,  or  hvpertrophied  edges  of  the  mucous  membrane 
which  fall  down  into  the  fissured  tract  or  ulcer  should  be  removed 
at  the  same  time  that  the  muscle  is  cut.  Unless  these  precautions 
are  taken  no  operation,  whether  by  incision  or  dilatation,  will  prove 
successful. 

Other  methods  of  incision  have  been  advised.  Hilton  advised  pass- 
ing a  sharp-pointed  bistoury  beneath  the  external  sphincter  muscle  and 
cutting  upward  through  the  ulceration.  Demarquay  (Archiv.  gen.  de 
med.,  1846,  p.  377)  advocated  the  submucous  incision  of  the  muscle.  By 
this  method  a  bistoury  is  passed  from  the  margin  of  the  anus  upward  be- 
neath the  mucous  membrane  and  ulceration  as  far  as  the  ulcer  extends, 
and  the  sphincter  is  then  cut  outward  until  relaxation  is  produced,  as 
is  done  in  the  subcutaneous  operations  for  contracted  tendons.  As 
Ball  states,  however,  this  operation  and  that  of  Copeland  could  only  be 
applied  to  those  cases  in  which  the  ulceration  was  very  slight  or  in 
which  there  was  no  ulceration  at  all,  but  simply  a  congestion,  in  which 
case  no  operation  is  necessary. 

Allingham  calls  attention  to  the  necessity  of  restoring  any  mal- 
formations of  the  uterus  before  attempting  operative  procedure  for 
fissure  in  women.  He  also  laj^s  great  stress  upon  the  necessity  of  keep- 
ing them  in  bed  after  whatever  procedure  is  adopted  whenever  there 
is  any  uterine  or  vesical  disease.  This  advice  is  certainly  wise,  and 
needs  only  to  be  mentioned  to  be  appreciated. 

Excision  of  Fissure. — In  our  discussion  of  the  patholog\'  and  eti- 
ology' of  fissure,  attention  has  been  called  to  a  class  of  cases  in  which 
there  is  marked  induration  and  cicatricial  formation  at  the  base.  It 
has  been  stated  that  in  a  certain  number,  although  the  ulcer  was  com- 
pletely healed,  the  patient  still  suffered  from  pains  of  a  dull,  aching, 
neuralgic  character  about  the  rectum.  These  facts  were  explained  by 
the  histological  studies  of  Hartmann,  which  demonstrated  that  these 
patients  not  only  suffered  from  an  ulceration  of  the  anus  but  also 
from  a  perineuritis  in  the  deeper  tissues  below  the  ulcer,  and  that 
neither  stretching  nor  incision  was  absolutely  sure  to  relieve  this  con- 
dition. Having  seen  a  number  of  such  cases  upon  wliich  divulsion  and 
incision  had  proved  failures,  the  author  concluded  some  three  3'ears  ago 


FISSURE  IN  AXO  315 

that  it  would  be  '^'ise  in  such  cases  to  dissect  out  the  indurated  mass  at 
the  same  time  that  lie  either  stretched  or  incised  the  sphincter.  Up 
to  the  present  time  he  has  operated  on  7  patients.  In  4  the  fissure 
was  uncomplicated^  and  after  dissecting  out  the  indurated  mass  and 
incising  the  sphincter,  the  freshened  edges  of  the  mucous  membrane 
and  skin  were  sutured  over  the  site  of  the  ulcer.  In  3  of  the  4  cases 
primary  union  took  place  and  the  patient  was  absolutely  well  at  the 
end  of  one  week.  In  the  fourth  case  infection  took  place  and  the 
stitches  had  to  be  removed  upon  the  third  day.  The  healing  was  some- 
what protracted,  but  the  pains  were  entirely  relieved,  and  the  patient 
made  a  good  recover}-  at  the  end  of  about  five  weeks.  In  the  other 
2  cases  in  which  the  dissection  was  done  the  fissure  was  complicated 
with  haemorrhoidal  disease.  In  one  of  these  the  modified  Whitehead 
operation  was  performed  after  dissecting  out  the  cicatricial  tissues  about 
the  fissure  and  incising  the  sphincter  muscle  upon  each  side  as  illus- 
trated (Fig.  108).  In  this  case  the  result  was  ideal,  both  in  regard 
to  the  haemorrhoids  and  the  fissure.  Primary  union  took  place  all 
around  the  anus,  and  at  the  end  of  ten  days  the  patient  left  the  hos- 
pital perfectly  well. 

In  the  sixth  case^,  in  which  the  excision  of  the  fissure  was  made, 
the  clamp-and-cautery  method  was  used  for  the  removal  of  the  haemor- 
rhoids and  left  the  fissure  wound  open  to  heal  by  granulation.  The 
patient  suffered  considerable  pain  following  the  operation,  lasting  for 
about  five  days.  He  was  a  hj^Dereesthetic  individual  incapable  of  suffer- 
ing patiently,  and  was  in  the  habit  of  taking  opiates  for  relief.  In 
his  case,  therefore,  it  was  necessary  to  administer  numerous  h}-po- 
dermics  of  morphine;  but  after  five  weeks  the  parts  were  healed,  and 
he  has  never  had  any  return  of  his  old  pains,  has  entirely  discontin- 
ued his  use  of  drugs,  and  he  is  now  attending  to  his  practice,  which  he 
had  practically  given  up  on  account  of  his  fissure.  Such  a  limited  num- 
ber of  cases  is  too  few  from  which  to  draw  any  broad  conclusions.  The 
results,  however,  would  seem  to  justify  a  wider  application  of  the  prin- 
ciple in  all  cases  in  which  the  dull,  aching  pain  following  faecal  move- 
ments indicates  the  involvement  of  the  deeper  nerve-trunks  in  a  process 
of  perineural  infiammation.  The  possibility  of  specific  taint,  even  in 
the  most  innocent,  has  led  in  all  cases  in  which  a  fissure  has  existed 
for  many  months  to  giving  the  patient  moderate  doses  of  mercury  and 
iodide  of  potash,  even  though  no  other  manifestations  of  the  disease 
were  present.  In  2  cases  in  which  the  fissure  had  already  been  incised 
by  other  operators  and  had  not  healed,  the  ulcer  was  cured  by  local 
applications  together  with  the  administration  of  this  mixed  treatment. 
Wliether  it  affected  an  obscure,  constitutional  S3^philis,  or  acted  by  its 
tonic  and  alterative  effect,  it  is  impossible  to  say.     The  necessity  of 


316  THE  ANUS,   RECTUM,  AND   PELVIC   COLON 

constitutional  treatment  in  cases  with  tubercular  and  anaemic  tendencies 
should  not  be  overlooked. 

One  other  feature  which  has  afforded  considerable  satisfaction  in 
some  of  these  cases  has  been  the  recognition  of  rheumatic  or  gouty 
symptoms  elsewhere  in  the  body;  these  influences  may  also  assume  con- 
siderable importance  in  the  neuralgic  and  aching  pains  of  fissure. 
Wherever  this  constitutional  tendency  exists  it  is  well  to  put  the 
patient  upon  nitrogenous  diet  and  administer  some  anti-rheumatics, 
such  as  salicylates  combined  with  alkalies;  Turkish  baths  at  regular 
intervals  will  also  be  useful  in  order  to  keep  the  skin  and  kidneys 
active. 

In  conclusion,  it  may  be  said  that  while  divulsion  will  be  suc- 
cessful in  the  majority  of  cases  in  which  the  fissure  is  laterally  located, 
and  in  which  there  is  no  considerable  induration  and  neuritis,  it  is 
by  no  means  an  absolutely  sure  method  for  the  treatment  of  fissure. 
Simple  incision  is  more  certain,  and  will  result  in  a  cure  in  the 
large  majority  of  cases.  It  has  the  advantage  that  it  does  not  re- 
quire general  anaesthesia,  being  done  under  the  influence  of  cocaine, 
and  it  maintains  the  relaxation  of  the  sphincter  muscle  for  a  much 
longer  period  than  is  accomplished  by  the  method  of  dilatation. 
Moreover,  where  the  ulcer  is  situated  above  the  external  sphincter  it 
furnishes  complete  drainage  and  avoids  the  accumulation  of  pus  and 
faecal  matter  in  the  depression  caused  by  the  ulcer.  This  method  is 
not  always  successful  in  cases  with  marked  induration;  in  those  the 
method  of  excision  is  the  safest  and  surest  so  far  as  rapid  and  com- 
plete cure  is  concerned;  and  this  also  may  be  done  under  cocaine. 

Many  of  these  cases  are  complicated  with  hemorrhoidal  disease,  and 
the  operation  upon  the  fissure  will  be  determined  by  the  method 
selected  for  the  operation  upon  the  haemorrhoids.  If  an  open  opera- 
tion, such  as  ligature,  crushing,  or  the  clamp  and  cautery  is  chosen 
for  the  haemorrhoids,  it  will  be  useless  to  attempt  to  sutiire  up  the 
wound  made  by  excision;  but  if  the  Whitehead  operation  is  adopted  for 
the  haemorrhoids,  then  the  edges  of  the  fissure  wound  should  be  closed 
at  the  same  time. 

Submucous  Fissure. — There  is  said  to  be  a  n^^mber  of  cases  in 
which  the  symptoms  of  fissure  are  associated  with  no  local  lesions  that 
can  be  made  out  by  either  digital  or  ocular  examination.  A  case  of 
this  type  has  been  described  elsewhere  in  the  chapter  on  fistula.  It  is 
not  a  true  fissure,  but  a  small  submucous  fistula  due  to  ulceration  and 
burrowing  downward  from  one  of  the  crypts  of  Morgagni.  There  is 
very  little  pus,  apparently  no  induration,  and  yet  the  patient  suffers 
at  and  after  every  stool  just  as  in  cases  of  acute,  uncomplicated  fissure 
in  ano.     It  can  be  diagnosed  by  the  introduction  of  a  bent  probe  into 


FISSURE  IN  ANO  317 

one  after  another  of  the  crypts;  when  the  diseased  crypt  is  reached  a 
very  acute  pain  will  be  excited.  An  incision  of  the  nracous  membrane 
overlying  this  little  fistulous  tract  is  not  sufficient  to  relieve  the  condi- 
tion; after  laying  open  the  fistula  the  sphincter  muscle  should  be 
incised  throughout  the  extent  of  the  tract  and  to  the  depth  of  about 
a  quarter  of  an  inch  below  its  surface.  This  will  relieve  the  fissure- 
like pain  and  in  a  short  time  radically  cure  the  trouble.  This  condi- 
tion is  rare,  but  it  is  very  distressing  to  the  patient  and  puzzling  to 
the  surgeon. 

The  Complications  of  Fissure. — Fissure  is  subject  to  the  same  com- 
plications as  all  other  ulcers  around  the  margin  of  the  anus  and  within 
the  anal  canal.  Acute  inflammatory  processes  may  set  up  from  infec- 
tion of  the  ulcer  due  to  its  being  torn  open  afresh  by  hard  fsecal  pas- 
sages, and  there  may  be  a  cellulitis,  a  phlegmonous  abscess,  or  a  fistula 
as  the  result.  Such  an  accident  may  also  follow  operations  by  incision 
or  divulsion.  It  is  necessary,  therefore,  to  call  attention  once  more  to 
the  necessity  of  antiseptic  precautions  in  all  operations  upon  the  rec- 
tum. Admitting  that  it  is  impossible  to  produce  absolute  asepsis  here, 
it  is  all  the  more  imperative  that  it  should  be  attained  as  nearly  as 
possible.  If  the  rectum  is  thoroughly  cleansed  at  the  time  of  an  opera- 
tion, and  the  wound  is  packed  with  sterilized  gauze,  this  will  generally 
protect  the  freshly  cut  surfaces  in  a  filter-like  way  until  healthy  granu- 
lation has  been  established.  Wliere  there  is  already  sepsis  present  in 
the  parts,  it  may  be  advisable  to  use  a  Paquelin  cautery  in  the  cutting, 
in  order  that  the  lymphatics  and  blood-vessels  will  be  sealed  at  the 
moment  and  thus  prevent  infection  by  whatever  germs  may  be  present 
in  the  wound  or  in  the  intestinal  canal.  This,  however,  is  rarely  if 
ever  necessary  in  the  treatment  of  simple  fissure;  and  as  it  is  likely,  if 
used  in  severing  the  sphincter,  to  cause  greater  contraction  of  that 
muscle  after  healing,  it  should  be  employed  with  the  greatest  caution. 
Hemorrhage  has  been  said  to  result  from  fissure  in  ano.  Undoubtedly 
such  might  possibly  occur,  as  has  been  reported  in  the  preceding  pages, 
but  as  a  rule  the  bleeding  is  only  of  a  trifiing  nature,  consisting  in 
two  or  three  drops  of  blood  after  fgecal  movements. 

Incontinence  is  said  to  have  resulted  from  incision  of  the  sphincter 
muscle  for  the  cure  of  fissure;  when  this  occurs  it  is  due  to  the  oblique 
incision  of  the  muscular  fibers.  There  are  mentioned  above  3  cases 
of  incontinence  following  stretching  of  the  sphincter  muscle  in  elderly 
people.  The  author  is  of  the  opinion  that  as  many  cases  of  inconti- 
nence result  from  too  rapid  and  too  great  divulsion  of  the  sphincter 
as  occur  from  single  incisions. 

Strictures  of  the  anus  and  rectum  have  been  said  to  result  from 
the  irritations  of  fissure.     Prolonged  and  spasmodic  contraction  of  the 


318  THE  ANUS,   RECTUM,   AND   PELVIC  COLON 

muscle  is  said  by  L'ripps  to  cause  abuonnal  shortening  and  fibrous 
degeneration  of  the  muscle,  and  to  result  in  true  stricture  upon  the 
level  of  the  external  sphincter,  or  more  particularly  in  that  portion 
of  the  rectum  and  anus  surrounded  by  the  levator  ani.  The  facts 
which  he  states  are  plausible,  and  we  must  admit  the  possibility  of 
such  a  result.  But  this  admission  only  emphasizes  the  necessity  of 
early  and  radical  treatment  of  all  ulcerations  and  fissures  about  the 
anus. 


CHAPTER   X 

PERIANAL  AND  PERIRECTAL   ABSCESSES 

The  tissues  surrounding  the  anus  and  rectum  are  subject  to  fre- 
quent iniiamniations  on  account  of  the  vast  amount  of  cellular  sub- 
stance, the  profuse  blood  supply,  and  the  numerous  lymphatics  of  this 
region.  This  may  be  brought  about  by  extension  from  rectal  and  anal 
inflammations,  by  obstruction  to  the  circulation,  by  the  inoculation 
of  septic  materials  through  some  of  the  glandular  tracts,  or  by  the 
deposit  of  these  agents  from  the  blood  or  lymphatic  circulations. 

Through  variations  of  pressure  due  to  the  presence  or  absence  of 
facal  masses  in  the  rectal  ampulla  and  to  changes  of  posture,  the  cir- 
culation of  the  parts  is  at  times  greatly  impeded,  and  at  others  abso- 
lutely free.  The  influence  of  these  variations  in  the  production  of 
inflammatory  processes  about  the  rectum  was  referred  to  by  Esmarch 
many  years  ago.  The  constant  presence  of  infectious  bacteria  in  the 
rectum  and  the  functional  action  of  the  organ  absorbing  fluids  from 
the  faeces  render  it  always  possible  for  these  agents  to  be  taken  up  by 
the  lymphatics  and  small  blood-vessels  and  lodged  in  the  perirectal 
tissues.  That  which  interests  us,  therefore,  from  a  pathological  point 
of  view  is  first,  the  character  of  the  pyogenic  bacteria,  and  secondly, 
the  nature  of  their  invasion. 

Recent  bacteriological  studies  have  thrown  considerable  light  upon 
the  infectious  agents  in  suppurating  processes.  We  have  learned  to 
distinguish  by  microscopic  examination  between  the  various  kinds  of 
pus"  discharged  from  abscess  cavities,  and  to  base  our  prog-noses  largely 
upon  the  known  phenomena  of  these  different  pyogenic  agents.  Among 
the  bacterial  contents  of  perirectal  abscesses  the  tubercle  bacillus  is 
frequently  present.  Koch  has  stated  that  tubercle  bacilli  are  never 
found  in  the  rectum  unless  there  exists  a  tubercular  ulceration  of  the 
intestines.  Sormanani,  after  a  prolonged  examination  and  stiidy  of 
the  subject,  attempts  to  explain  the  absence  of  tubercle,  bacilli  in  the 
fsecal  discharges  upon  the  grounds  that  these  bacilli  are  destroyed  by 
the  action  of  the  gastric  juice  and  therefore  disappear  in  their  passage 
through  the  stomach.     His  examinations,  however,  simply  showed  the 

319 


320  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

general  absence  of  tubercle  bacilli  in  the  fcccal  discharges,  and  his 
explanation  of  this  absence  was  purely  theoretical.  On  the  other  hand, 
von  Jaksch  and  others  have  succeeded  in  finding  the  tubercle  bacilli  in 
the  stools  of  patients  not  affected  with  intestinal  ulceration;  and  C'ar- 
riere  (Compt.  rendus  soc.  biol.,  101,  p.  1098)  has  shown  by  elaborate 
and  patient  experiments  that  exposure  of  tubercle  bacilli  to  both  natural 
and  artificial  gastric  juice  for  twelve  hours  or  more  has  no  effect  upon 
their  virulence.  Simmons  (Miinchener  med.  Woch.,  1900,  p.  317)  has 
demonstrated  that  while  the  gastric  juice  prevents  the  multiplication 
of  tubercle  bacilli,  it  in  no  wise  destroys  them,  and  after  this  secretion  is 
neutralized  by  the  alkaline  fluids  of  the  intestine,  the  bacilli  may  go  on 
and  develop  just  as  if  they  had  never  been  exposed  to  the  gastric  fluids. 
From  these  experiments  there  is  no  longer  any  doubt  but  that  tlie  bacilli 
reach  the  sigmoid  and  rectum  through  the  digestive  tract  independent 
of  ulcerations  higher  up  in  the  intestine. 

It  is  no  unusual  experience  to  find  a  tubercular  abscess  at  the 
margin  of  the  anus  or  in  the  perirectal  cellular  tissues,  as  the  first 
manifestation  of  tuberculosis,  and  it  is  unreasonable  to  suppose  that 
the  bacillus  enters  through  the  respiratory  apparatus  and  passes  through 
the  lungs  into  the  circulation,  and  then  lodges  in  this  particular  spot 
when  it  is  possible  to  take  a  shorter  and  more  direct  route  through 
the  intestinal  canal.  How  it  enters  the  canal  in  cases  with  tidjerculosis 
of  the  nares,  throat,  and  lungs,  is  very  easily  explained  by  the  fact  that 
these  patients  often  swallow  the  discharges  and  sputa.  The  bacilli  may 
be  carried  to  the  parts  by  patients  handling  handkerchiefs  or  objects 
which  have  been  used  by  the  tuberculous,  and  thus  cause  local  infection; 
it  is  also  possible  that  the  use  of  syringe-tips,  bougies,  and  other  rectal 
instruments  which  have  been  used  upon  tuberculous  patients,  may 
carry  the  germs  and  deposit  them  upon  non-tubercular  patients. 
Whether  it  is  possible  for  these  germs  to  be  carried  by  detergent  sub- 
stances, clothing,  etc.,  or  wafted  through  the  air,  is  a  question  for 
bacteriologists  to  decide.  The  fact,  however,  remains  that  we  do  have 
tubercular  abscesses  and  ulcerations  around  the  anus,  and  sometimes 
in  the  rectum  in  cases  in  which  there  are  no  other  tubercular  foci.  It 
is  impossible  to  come  to  any  other  conclusion  than  tliat  these  are  local 
infections,  and  that  the  bacilli  reach  the  parts  through  the  digestive 
tract. 

The  next  most  frequent  infectious  agent  found  in  abscesses  and 
inflammations  about  the  rectum  is  the  Bacterium  coli.  The  fact  that 
this  bacillus  is  so  often  found  in  perirectal  abscesses  is  not  conclusive 
evidence  as  to  its  etiological  influence.  Pathologists  tell  us  it  is  the 
cause  of  suppuration,  that  it  passes  out  between  the  tissues  in  the 
same  manner  that  the  white  blood-corpuscles  and  amoebae  pass  from 


PERIANAL  AND   PERIRECTAL  ABSCESSES  321 

the  blood-vessels  and  invades  areas  at  a  distance  from  the  intestinal 
tract.  It  is  always  present  in  the  large  intestine,  and  needs  only  the 
slightest  injury  of  the  epithelial  surface  to  afford  it  an  entrance  into 
the  tissues.  Such  lesions  are  frequent  enough,  and  inasmuch  as  the 
bacillus  is  always  present,  the  question  arises  why  it  sometimes  forms 
abscesses  and  sometimes  does  not.  Recent  studies  by  Vaughan  seem  to 
point  to  a  probable  explanation  of  these  facts.  He  stated  that  the 
toxic  principle  of  the  bacillus  is  enclosed  in  a  capsule,  and  that  it  does 
not  produce  inflammation  or  toxic  symptoms  until  this  cap.sule  is  broken 
or  dissolved.  Ordinary  alkalines  have  no  effect  upon  this  capsule.  Nor- 
mal gastric  secretions  will  dissolve  it  and  set  the  toxic  principle  free; 
and  furthermore,  he  considers  it  possible  that  the  blood  serum  may 
also  have  this  effect.  Therefore,  when  the  bacillus  enters  into  a  tissue 
largely  supplied  with  capillary  circulation,  its  capsule  may  be  dissolved, 
thus  setting  the  toxic  principle  free  and  establishing  inflammatory  pro- 
cesses which  eventuate  in  supjDuration.  Thus  the  fact  that  normal 
Bacterium  coli  is  found  in  the  discharge  from  an  abscess  does  not  prove 
that  this  is  the  cause  of  the  abscess.  If  its  capsule  is  intact  it  is  proba- 
bly innocuous.  It  is  rarely  found  alone,  but  almost  always  associated 
with  other  pyogenic  bacteria,  such  as  the  staphylococcus,  streptococcus, 
and  tubercle  bacillus.  Hartmann  and  Lieffring  in  a  study  (Bull,  de  la 
soc.  d'anat.  de  Paris,  1883,  pp.  69,  161,  517)  on  the  character  of  bacilli 
found  in  perirectal  abscesses,  state  that  in  7  out  of  10  cases  they  estab- 
lished the  existence  of  tubercle  bacilli.  In  4  of  these  cases  this  bacillus 
was  associated  with  the  Bacterium  coli.  In  only  3  cases  out  of  the 
18  studied  were  they  able  to  find  the  Bacterium  coli  alone.  Twice  they 
found  the  Staphylococcus  aureus  in  a  pure  state.  In  1  case  the  microbe 
of  tetanus  was  found,  and  in  another  staphylococci  associated  with 
Bacterium  coli  and  saprophytes.  In  numerous  examinations  which  have 
been  made  for  the  author  of  pus  taken  from  abscesses  around  the  anus 
and  rectum,  no  case  has  been  seen  in  which  the  Bacterium  coli  was  not 
associated  with  either  tubercle  bacilli,  streptococci,  or  staphylococci. 
Achard  and  Lannelongue  (Bull,  med.,  1893,  p.  73)  have  confirmed  the 
observations  of  Hartmann  and  Lieffring  by  the  report  of  a  case  of 
abscess  of  the  margin  of  the  anus,  in  the  pus  from  which  only  the 
colon  bacterium  was  found.  Muscatello  (La  reforme  med.,  1891,  p.  145) 
has  also  reported  a  similar  case.  In  all  cases,  however,  infectious  germs 
of  some  kind  have  been  found.  We  may  therefore  assume  that  the 
septic  origin  of  perirectal  abscesses  is  thoroughly  established,  and  that 
the  old  theories  of  idiopathic,  gangrenous  cellulitis,  and  suppuration 
are  no  longer  tenable. 

Course  of  Infection. — The  methods  by  which  such  infection  gains 
an  entrance  to  the  tissues  must  therefore  be  studied  in  order  to  account 
21 


322  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

for  the  variations  in  character  and  course  of  these  different  types  of 
inflammation.  The  first  and  most  easily  understood  method  is  through 
some  lesion  of  the  mucous  membrane  or  of  the  skin  in  these  regions. 
Wounds  or  injuries  to  the  parts  from  whatever  cause  may  afford  en- 
trance to  the  infectious  agents  into  the  perianal  or  perirectal  cellular 
tissues.  The  nature  and  depth  of  the  wound  sometimes  govern  the 
extent  of  the  infection,  but  the  character  of  the  germ  and  the  activity 
of  the  lymphatic  and  general  circulation  have  much  more  to  do  with  it. 
These  lesions,  while  they  account  for  the  entrance  of  bacilli,  do  not 
furnish  us  any  information  as  to  the  route  that  they  travel  in  their 
invasion  of  the  different  perirectal  tissues.  There  is  a  certain  num- 
ber of  abscesses  which  involve  only  the  skin  or  mucous  membrane. 
In  these  cases  the  entrance  of  the  bacillus  is  probably  through  some 
of  the  glandular  organs  of  these  teguments,  such  as  the  hair  follicles, 
the  sebaceous  glands,  and  the  solitary  or  Lieberklihn  follicles. 

These  abscesses  are  nothing  more  than  exaggerated  furuncles,  some- 
times limited  even  to  an  aeneous  nature.  The  lymphatics  of  the  skin 
may  become  involved  in  these  cases,  and  through  them  an  infection, 
which  originally  only  involved  a  small  glandular  crypt,  will  invade  a 
larger  area.  Such  abscesses  remain  in  this  superficial  lymphatic  system 
and  do  not  involve  the  deeper  tissues  of  the  ischio-rectal  fossa  or  the 
superior  pelvic  spaces. 

Eczema,  herpes,  abrasions  from  the  clothing,  and  irritation  due 
to  improper  detergent  substances,  may  furnish  an  entrance  to  the  infec- 
tious agents  which  are  swept  over  the  part  during  defecation.  The 
course,  however,  is  the  same  as  that  just  described. 

Other  marginal  abscesses  occur  as  the  result  of  thrombi  or  throm- 
botic hemorrhoids.  The  question  has  been  asked  how  infection  enters 
through  a  thrombotic  hemorrhoid.  If  these  little  thrombi,  due  to  the 
rupture  of  small  veins  around  the  margin  of  the  anus,  are  examined, 
it  will  be  seen  that  they  are  very  close  to  the  surface  of  the  skin  or  the 
muco-cutaneous  tissue.  The  tension  produced  by  the  extravasation  of 
blood  in  the  cellular  tissue  is  quite  considerable,  and  it  is  altogether 
possible  that  this  tension  may  result  in  rupture  of  some  of  the  se- 
baceous or  hair  follicles  in  the  deeper  areas  of  the  skin,  thus  affording 
whatever  bacilli  exist  in  these  follicles  or  upon  the  surface  of  the  skin 
an  entrance  into  the  subcutaneous  tissue.  On  the  other  hand,  pyogenic 
agents  which  circulate  in  the  blood  with  impunity,  when  poured  into  a 
stagnant  area  may  find  a  congenial  menstruum  in  which  to  multiply, 
and  thus  produce  infection.  Necroses  from  pressure  or  rupture  of  the 
cutaneous  or  mucous  glands  are  probably  the  routes  of  infection  in 
most  cases. 

Desprey  formerly  accounted  for  marginal  abscess  upon  the  theory 


PERIANAL  AND   PERIRECTAL  ABSCESSES  323 

of  supiraratixLg  phlebitis,  but  that  disease  is  always  accompanied  by 
serious  constitutional  symptoms,  and  in  these  cases  such  are  absent  as 
a  rule.  As  to  the  entrance  of  bacilli  into  the  deeper  perirectal  tissues, 
certain  cases  may  be  explained  by  the  perforation  of  the  rectal  wall 
either  by  foreign  bodies,  such  as  pins,  fish-bones,  syringe-tips,  or  occa- 
sionally by  ulcerative  processes  in  the  mucous  membrane.  It  is  hardly 
reasonable  to  suppose  that  infections  originating  in  this  way  could  pro- 
duce abscesses  not  connected  with  the  rectum,  and  yet  it  is  undoubt- 
edly a  fact  that  a  large  number  of  these  perirectal  abscesses  have  no 
connection  with  the  rectum  in  the  beginning.  That  they  eventuate  in 
fistula  is  due  in  most  cases  to  delay  in  operative  treatment  or  to  improp- 
erly conceived  surgical  procedures.  It  is  believed  that  perforating  in- 
juries of  the  rectum  and  anal  wall  will  account  for  only  a  very  few  peri- 
rectal abscesses. 

The  reader  who  has  closely  studied  the  arrangement  of  the  hnn- 
phaties,  as  described  in  the  chapter  upon  the  anatomy  of  the  rectum, 
will  remember  that  the  superficial  vessels  of  this  system  which  sur- 
round the  anus  pass  forward  through  the  perin^eum  to  join  the  inguinal 
chain  of  glands,  or  backward  to  that  behind  the  sacrum;  the  deeper  ones 
pass  throiigh  the  ischio-rectal  spaces  to  the  hypogastric  chain,  and  those 
around  the  rectum  pass  upward  to  join  the  sacral  and  vertebral  ganglia. 
It  has  been  proved  beyond  the  shadow  of  a'  doubt  that  infection  travels 
along  the  lymphatic  tracts.  It  is  not  the  veins  or  the  arteries  in  which 
septic  germs  are  found  in  angeioleucitis,  but  the  lymphatic  vessels. 
Septic  infections  of  the  extremities  travel  rapidly  to  the  axilla  and 
groin  along  the  lymphatic  channels.  In  the  same  manner  infectious 
bacteria  enter  the  jDerirectal  tissues.  It  is  not  necessary  that  there 
should  be  a  puncture  or  deeiD  wound  for  this  to  occur.  The  lymphatics 
in  the  skin  and  perianal  tissues  travel  in  a  superficial  plane.  Thus, 
infections  which  enter  these,  spread  either  toward  the  scrotum  and 
groin  or  backward  toward  the  sacrum.  The  hrmphatics  which  originate 
in  the  submucous  area  and  in  the  columns  of  Morgagni  pass  upward 
and  outward  through  the  muscular  fibers  of  the  rectal  wall  and  into 
the  cellular  tissue  which  fills  up  the  ischio-rectal  and  the  retro-rectal 
spaces.  These  lymphatic  networks  anastomose  with  one  another, 
although  the  currents  fiow  in  opposite  directions.  The  limits  of  the 
extension  of  sepsis  is  explained  by  the  formation  of  thrombosis  or  in- 
flammatory obstructions  in  these  channels,  thus  demonstrating  one  of 
the  conservative  processes  of  nature.  THien  the  infection  is  checked 
in  this  manner  in  one  direction  it  may  flow  backward  and  progress 
in  another.  Thus  an  infection  originating  in  the  superficial  tissues 
may  be  checked  in  its  progress,  and  through  the  anastomosis  may  in- 
vade the  deeper  tissues  and  so  produce  a  combination  of  the  superficial 


324  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

and  profound  infection.  These  facts  with  regard  to  the  thromboses  of 
lymphatic  trunks  have  been  established  by  the  bacteriological  studies  of 
Metchnikolf  and  by  the  clinical  observations  of  Chassaignac. 

The  fact  that  abscesses  occasionally  develop  at  a  considerable 
distance  from  the  anus,  following  minor  operations  for  haemorrhoids 
or  fissure,  can  only  be  explained  through  this  method  of  invasion.  The 
lymphatic  system  which  connects  with  those  subtegumentary  areas  of 
the  buttocks  is  that  described  as  the  middle  ha^morrhoidal  lymphatic 
system.  The  superior  ha?morrhoidal  lymphatic  system  connects  with 
the  gluteal  tissues  through  the  ischiatic  notch  and  the  obturator  fora- 
men; thus  injuries  in  the  anal  canal  are  likely  to  be  followed  by 
abscesses  either  in  the  ischio-rectal  fossa  or  in  the  cutaneous  tissues 
of  the  buttocks,  while  those  that  occur  in  the  rectum  proper  are  very 
likely  to  be  associated  with  abscesses  of  the  retro-rectal  space  and  of 
the  deeper  submuscular  tissue  of  the  thigh. 

The  etiological  factors  therefore  in  perirectal  and  perianal  inflam- 
mations or  abscesses  are  the  various  infectious  germs  which  are  found 
in  the  rectum  and  the  lymphatic  system  which  furnishes  these  germs 
a  means  of  emigration  into  the  surrounding  tissues.  "  The  richness  of 
the  subsphincterian  lymphatic  network,  the  Ijunches  of  lymphatic 
trunks  contained  in  the  columns  of  ]\Iorgagni,  the  frequency  with  which 
these  lymphatics  are  exposed  to  openings  by  slight  abrasions  and  be- 
come immediately  contaminated,  exphiin  for  us  the  frequency  of  ab- 
scesses of  the  anus  "  (Quenu  and  Hartmann,  vol.  i,  p.  131). 

A  recent  and  scientific  classification  of  perirectal  inflammations  l)y 
Quenu  and  Hartmann  is  so  elaborate  as  to  be  confusing  to  the  gen- 
eral student,  however  satisfactory  it  may  appear  to  the  specialist.  They 
may  be  broadly  classified  as  Circumscribed  and  Diffuse  Inflammations; 
and  under  these  the  special  forms  may  be  arranged.  A  sort  of  tabular 
statement  of  this  division  is  as  follows: 

r  ( Tegumentary. 

Circumscribed  inflammations  or  ab-   I  Superficial  I  Subtegumentary. 

seesses )  ^  Ischio-rectal. 

(  Retro-rectal. 
Profound    -  Superior  pelvi-rectal. 
(  Interstitial. 

Diffuse  inflammations ^ i  Diffuse  perirectal  cellulitis. 

(  Gangrenous  perirectal  cellulitis. 

The  order  of  sequence  ordinarily  adopted  by  writers  upon  this 
subject  is  violated  in  this  classification  because  the  circumscribed 
inflammations  are  very  much  more  frequent  in  occurrence  and  less 
serious  in  their  nature;  moreover,  the  diffuse  variety  may  result  from 
them. 

Of  the   circumscribed   inflammations,   those   which   are   below   the 


PERIANAL   AND   PERIRECTAL   ABSCESSES  325 

levator  ani  muscle  are  called  superficial,  and  those  above  it  profound. 
Of  each  type  there  are  three  varieties,  according  to  the  tissues  or  areas 
involved. 

Superficial  Abscesses. — The  circumscribed  superficial  inflammations 
are  tegumentary,  subtegumentar}^,  and  ischio-rectal. 

Tegumentary  Abscess. — This  is  the  simplest  form  of  circumscribed 
perianal  inflammation.  They  are  due  to  infection  of  the  follicular  or 
glandular  portions  of  the  skin,  and  muco-cutaneous  membrane  about 
the  margin  of  the  anus.  They  may  be  very  properly  termed  follicular 
abscesses.  The  term  "  tubereux,"  used  by  the  French,  descriptive  of 
this  form  of  inflammation,  is  very  misleading,  in  that  it  is  often  as- 
sumed to  ascribe  a  tuberculous  etiology  to  the  condition.  The  inflam- 
mation may  be  due  to  any  one  of  the  septic  or  infectious  germs.  It  is  a 
direct  infection  and  not  due  to  any  l3anphatic  propagation.  It  may  be 
brought  about  by  irritation  of  the  glands  from  chafing,  horseback-riding, 
improper  detergent  substances,  rough  clothing,  and  scratching  of  the 
parts.  Stout,  well-fed,  inactive  individuals,  not  overly  attentive  to  the 
hygiene  of  the  parts,  are  very  liable  to  this  affection. 

They  develop  as  little  furuncles  or  aeneous  pimples  about  the  mar- 
gin of  the  anus,  varying  in  size  from  that  of  a  bird-shot  to  a  good-sized 
hazelnut.  Their  symptoms  are  identical  with  those  of  follicular  in- 
flammation of  the  skin  elsewhere,  beginning  in  a  congestion  followed 
by  swelling  of  the  follicle,  which  eventually  opens  spontaneously  and 
discharges  its  contents  either  as  a  thin  purulent  fluid  or  as  a  necrotic 
mass  called  a  "  core."'  Occasionally  these  abscesses  assume  a  graver  type 
resembling  a  carbuncle.  The  inflammation  or  infection  extends  from 
one  follicle  to  another  until  a  large  area  of  skin  is  involved  which  may 
open  at  several  distinct  j)laces  close  to  the  mouths  of  the  separate  folli- 
cles involved.  The  final  discharge,  however,  of  a  central  necrotic  mass 
shows  distinctly  the  nature  of  the  disease,  notwithstanding  the  fact 
that  it  sometimes  perforates  the  derma  and  invades  the  subcutaneous 
or  submuscular  tissues.  This  latter  condition  is  a  complication  and 
not  a  part  of  the  real  tegumentary  abscess.  Patients  generally  de- 
scribe these  abscesses  as  boils.  They  may  be  single  or  multiple,  and 
sometimes  one  succeeds  the  other  until  the  patient's  life  is  made  miser- 
able by  their  continued  presence  around  the  margin  of  the  anus.  As  a 
rule  they  do  not  involve  the  anal  canal  itself,  but  are  limited  to  the 
cutaneous  tissue  about  the  margin.  They  do  not  therefore  interfere 
seriously  with  defecation,  and  are  not  the  cause  of  any  functional  de- 
rangements of  the  intestinal  canal.  They  interfere  with  sitting  or  walk- 
ing, and  may  necessitate  confinement  to  bed  for  greater  or  less  periods 
of  time  simply  on  account  of  the  discomfort  produced.  There  are 
usually  no  constitutional  symptoms  such  as  chill,  fever,  and  loss  of 


326  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

appetite,  althougli  the  temperature  may  be  elevated  a  degree  or  more. 
It  is  a  localized  disease. 

In  a  neighborhood  so  richly  endowed  with  lymphatics  both  of  the 
deep  and  superficial  channels  there  is  always  a  possibility  of  septic  germs 
being  takeii  up  from  any  focus  and  carried  to  other  regions  and  infect- 
ing them.  These  little  abscesses  are  fairly  well  protected  from  such 
dangers  by  the  walls  of  the  follicles,  which  are  more  resisting  than  the 
overlying  epithelium,  and  hence  opening  and  drainage  generally  occurs 
in  the  latter  direction  before  the  cellular  tissue  is  involved. 

Treaiment. — The  management  of  these  cases  is  rather  therapeutic 
than  surgical.  Diffuse  inilammations  and  perirectal  abscesses  have  fol- 
lowed the  reckless  opening  of  superficial  abscesses  about  the  margin  of 
the  anus  or  upon  the  buttocks.  A  good  plan  in  these  cases  is  to  make 
a  very  small  opening  and  then  apply  pure  ichthyol  or  carbolic  acid 
upon  a  fine  applicator  to  the  interior.  The  free  application  of  pure 
ichthyol  will  frequently  dissipate  these  little  inflammations  or  hasten 
their  resolution  if  simply  painted  over  the  surface  two  or  three  times 
a  day  without  any  incision  being  made.  Heitzman  advised  the  applica- 
tion of  an  ointment  of  10  per  cent  salicylic  acid  and  90  per  cent  of 
glycerin  ointment,  especially  in  those  cases  in  which  these  little  ab- 
scesses had  a  tendency  to  recur;  the  ointment  was  given  to  the  patient, 
and  he  was  instructed  to  apply  it  the  moment  he  had  any  pain  at  a 
given  spot,  and  in  this  way  suppuration  has  been  prevented  in  a 
number  of  cases,  but  it  is  not  uniformly  successful  in  this  respect.  Dr. 
Swinburne  stated  that  he  had  been  successful  in  aborting  suppuration 
in  many  of  these  cases  by  the  injection  of  a  strong  solution  of  salcylic 
acid  into  the  inflamed  follicle. 

Attention  to  cleanliness  is  of  the  utmost  importance,  and  bathing 
of  the  parts,  especially  after  defecation,  with  antiseptic  solutions,  should 
be  advised. 

Excision  of  these  small  isolated  inflammatory  foci  has  been  tried 
a  number  of  times.  In  the  author's  hands  it  has  not  proved  successful 
in  the  neighborhood  of  the  rectum,  owing  to  the  fact  that  it  is  almost 
impossible  to  sterilize  the  cutaneous  tissues  of  this  region.  Moreover, 
as  stated  before,  these  abscesses  are  confined  to  the  derma,  and  com- 
plete excision  would  only  necessitate  the  invasion  of  the  subcutaneous 
tissues  and  thus  expose  parts  to  infection  which  are  ordinarily  exempt. 
It  is  better,  on  the  whole,  to  depend  upon  the  applications  of  ichthyol 
or  salicylic  acid  where  these  small  abscesses  open  spontaneously;  if  they 
do  not  so  open,  puncture  the  apex  with  a  small  bistoury,  and  after 
emptying  the  cavity  fill  it  with  pure  ichthyol.  The  patient  should  be 
kept  in  a  recumbent  posture  until  the  acute  inflammatory  symptoms 
have  disappeared. 


PERIANAL  AND   PERIRECTAL   ABSCESSES  327 

Subtegumentary  Abscesses. — Circumscribed  inflammations  of  the 
subcutaneous  and  submucous  tissues  are  among  the  commonest  results 
of  anal  and  rectal  lesions,  and  are  rarely  if  ever  idiopathic.  They  are 
caused  by  infection  of  the  lymphatics.  Although  they  can  not  always 
be  traced  to  any  definite  solution  of  continuity  in  the  skin  or  mucous 
membrane,  it  is  probable  that  in  the  large  majority  of  cases  they 
originate  in  some  such  lesion.  The  infection  is  carried  thence  by  the 
lymphatics  into  the  cellular  tissues  until  it  is  arrested  either  in  the 
glandular  apparatus  or  by  thrombus  of  the  lymphatic  trunks,  thus 
limiting  it  to  a  focus  in  which  it  proceeds  to  multiply  and  destroy  the 
tissues,  causing  a  circumscribed  inflammation  and  abscess.  Chassaig- 
nac,  Kelsey,  Hartmann,  and  others  claim  that  these  abscesses  may 
develop  in  isolated  external  or  internal  hsemorrhoids  due  to  a  phlebitis 
of  the  hemorrhoidal  vessels.  They  do  not  account  for  the  phlebitis 
in  any  way,  nor  do  they  state  whether  the  abscess  causes  thromboses 
of  the  veins  or  whether  the  thromboses  precede  the  abscess.  Fre- 
quently such  abscesses  follow  what  are  termed  thrombotic  hsemorrhoids, 
but  they  always  succeed  the  formation  of  a  clot,  and  do  not  occur  until 
several  days  later.  It  is  difficult  to  conceive  of  such  a  circumscribed 
phlebitis  as  would  cause  clotting  of  the  blood  and  abscess  in  one  little 
hsemorrhoid  without  any  inflammation  of  the  other  venous  trunks  with 
which  it  is  connected,  or  any  constitutional  symptoms  such  as  are  found 
in  the  ordinary  phlebitic  process.  It  seems  justifiable  therefore,  in  the 
light  of  modern  pathological  investigation,  to  assert  that  subcutaneous 
perirectal  and  perianal  inflammations  are  always  due  to  infection  of 
immediate  or  remote  injuries  to  the  sTcin  or  mucous  membrane,  and  that 
the  propagation  of  this  infection  is  along  the  tracts  of  the  lymphatic 
apparatus.  The  sources  of  such  injuries  have  already  been  mentioned 
and  need  not  be  repeated  here.  These  abscesses  may  be  subcutaneous, 
submucous,  or  submuco-cutaneous.  They  are  more  frequent  in  middle 
age,  rarely  occurring  in  the  very  old  or  very  young,  with  the  exception 
of  one  variety,  the  tuberculous,  which  does  occur  very  frequently  in 
children  from  two  to  six  years  of  age. 

Symptoms. — The  symptoms  of  this  variety  of  abscess  are  variable. 
Sometimes  they  develop  obscurely  without  chill  or  fever,  with  very 
slight  if  any  pain,  opening  spontaneously  and  discharging  small  quanti- 
ties of  white,  thin  pus.  Such  a  course  is  generally  indicative  of  a 
tubercular  process.  Ordinarily  the  physician  is  only  consulted  in  these 
cases  after  rupture  and  discharge  of  pus.  He  then  finds  a  soft,  boggy 
mass  with  a  small  ulcerative  opening  either  through  the  skin  or  muco- 
cutaneous tissue,  from  which  there  oozes  a  thin,  watery  pus  upon  pres- 
sure. There  is  very  little  evidence  of  inflammatory  reaction  such  as 
induration,  redness,  and  pain  about  the  parts.     The  skin  or  muco- 


328  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

cutaneous  tissue  is  undermined  in  all  directions  around  the  opening, 
and  if  not  properly  taken  care  of  this  burrowing  or  undermining  is 
likel}'  to  proceed  to  an  indefinite  extent.  Sometimes  it  burrows  up- 
ward beneath  the  muco-cutaneous  tissues  and  forms  a  fistulous  tract 
between  the  coats  of  the  rectum.  This  burrowing  may  take  place  before 
the  abscess  opens.  The  opening  then  may  occur  in  the  rectal  cavity, 
thus  forming  a  blind  internal  fistula. 

At  other  times  these  abscesses  are  ushered  in  by  marked  constitu- 
tional symptoms.  The  patient  is  attacked  Avith  a  distinct  chill,  the 
pulse  is  accelerated,  the  temperature  elevated,  and  there  is  a  feeling 
of  general  malaise.  Locally  there  is  at  first  a  feeling  of  discomfort 
which  gradually  increases  to  actiial  pain.  Local  examination  discloses 
a  hard,  swollen  area  at  some  j)ortion  of  the  anal  circumference,  hot, 
red,  or  violaceous,  painful  to  the  touch,  and  throbbing  constantly; 
cases  with  such  acute  constitutional  sej^tic  symptoms,  in  which  there 
w^as  a  bacteriological  examination  of  the  contents  of  abscesses,  have 
usually  shown  the  presence  of  streptococci  and  colon  bacteria.  These 
acute  inflammatory  symptoms  have  never  been  met  wdth  in  cases  of 
pure  tubercular  abscesses.  The  severity  of  the  pain  seems  to  be 
proportionate  to  the  height  of  the  abscess.  This  can  be  understood 
for  two  reasons:  the  farther  we  ascend  into  the  anal  canal  the  more 
closely  are  the  skin  and  muco-cutaneous  tissues  attached  to  the  mus- 
cular and  fibrous  aponeuroses;  there  is  less  cellular  tissue  in  which 
the  abscess  can  distend,  and  the  spasm  of  the  sphincter  produced 
by  the  inflammatory  processes  also  contributes  to  increase  the  pain. 
Sometimes  the  abscesses  develop  entirely  within  the  anal  canal,  in 
W'hich  case  one  sees  no  outward  manifestation  of  the  same  until  the 
buttocks  are  forcibly  distended  or  the  finger  is  introduced  into  the 
anus,  when  a  protruding,  globular  mass,  either  indurated  or  fluctuating, 
painful  to  the  touch  and  obstructing  the  anal  canal,  will  be  found. 
If  left  alone  they  open  spontaneously  either  through  the  skin  or  the 
muco-cutaneous  tissues;  they  rarely  open  into  the  rectum  proper;  they 
may  open  near  the  upper  limits  of  the  anal  canal  and  thus  form  what 
is  termed  an  internal,  blind  muco-cutaneous  fistula,  or  they  may  open 
upon  the  skin  to  form  an  external  blind  fistula.  The  moment  they 
open,  at  whatever  height  or  in  whatever  manner,  they  constitute  what 
is  commonly  called  a  fistula  of  one  variety  or  another,  and  what  is  still 
more  typical  they  do  not  drain  and  heal  as  simple  abscesses  elsewhere, 
but  remain  fistulous  unless  laid  open  throughout  their  whole  extent. 
No  explanation  of  this  fact  has  been  given,  but  every  clinical  observer 
is  so  familiar  wath  it  that  he  never  hesitates  in  these  subtegumentary 
abscesses  of  the  anal  canal  to  carry  his  incision  to  the  full  height  of 
the  cavity  when  he  opens  them,  in  order  to  avoid  secondary  operations. 


PERIANAL  AND   PERIRECTAL  ABSCESSES 


529 


When  these  abscesses  open  within  the  anus  and  upon  the  skin  at 
the  same  time,  as  they  sometimes  do,  they  form  complete  subtegu- 
mentary  fistulas.  In  a  very  small  mmiber  of  cases  the  infection  may  be 
circumscribed  in  the  submucous  tissue  of  the  intestinal  wall  and  thus 
form  an  intramural  abscess 
of  the  rectum  (Fig.  109). 
These  cases  will  be  accom- 
panied with  mild  constitu- 
tional symptoms,  such  as 
headache,  a  slight  eleva- 
tion of  temperature,  heavi- 
ness and  aching  in  the  pel- 
vis, pain  on  defecation,  and 
sometimes  dysuria.  The 
symptoms  resemble  those 
of  an  inflamed,  internal 
hsemorrhoid,  and  unless 
one  is  educated  in  digital 
examination  he  may  mis- 
take one  condition  for  the 
other.  In  these  cases  the 
finger  will  discover  a  glob- 
ular, doughy,  or  elastic 
mass  in  the  rectum,  some- 
times fluctuating,  sometimes  hard,  generally  in  one  or  other  of  the  ante- 
rior quadrants.  The  mucous  membrane  may  or  may  not  move  over  the 
surface  of  the  mass.  By  pressure  downward  with  the  finger  of  one  hand 
above  the  mass,  and  that  of  the  other  upon  the  external  margin  of  the 
anus,  the  swelling  may  be  outlined  and  grasped,  but  it  does  not  extend 
near  the  cutaneous  tissues.  Its  superficial  location  in  these  cases  can  be 
well  determined  by  the  experienced  surgeon.  It  is  a  matter  of  the  great- 
est importance  that  this  should  be  done,  for  the  opening  of  these  intra- 
mural abscesses  by  deep  incision  through  the  skin  and  perineal  tissues  is 
likely  to  result  in  diffuse,  inflammatory  perijjroctitis,  and  is  almost  cer- 
tain to  result  in  fistula.  While  these  subtegimientary  abscesses  are  gener- 
ally circumscribed  and  of  small  extent,  they  may  also  assume  a  phleg- 
monous type,  extend  over  large  areas,  and  invade  the  deeper  tissues. 

The  author  has  seen  one  case  that  originated  in  this  variety  of 
abscess  in  which  the  whole  skin  of  the  peringeum  was  undermined  from 
the  scrotum  to  the  coccyx,  and  from  one  tuberosity  to  the  other.  The 
abscess  or  burrowing  eventually  extended  upward  and  forward  into  the 
inguinal  region,  resulting  in  suppuration  of  the  glands  of  these  parts. 
This  patient  recovered  after  prolonged  constitutional  treatment   and 


Fig.  109. — Inteamubal  ok  Submucous  Abscess  of 
THE  Kectum. 


330  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

numerous  surgical  operations.  Bacteriological  examination  of  the  dis- 
charges were  carefully  made,  but  at  no  time  was  the  pathologist  able 
to  demonstrate  the  presence  of  any  other  types  than  those  of  Staphy- 
lococcus albus  and  colon  bacteria.  Those  cases  which  progress  to  the 
involvement  of  the  deeper  areas  may  be  properly  considered  under  the 
subject  of  ischio-rectal  and  profound  abscesses. 

Treatment. — The  treatment  of  subtegumentary  abscesses  is  purely 
a  surgical  one.  Ice  poultices  and  antiphlogistic  remedies  have  no  place 
in  the  treatment  of  this  condition.  "Wlienever  a  subtegumentary  indura- 
tion or  swelling  has  been  determined,  unless  complicated  with  syphilitic 
or  malignant  disease,  immediate  and  free  incision  should  be  made 
whether  pus  has  already  formed  or  not.  If  the  swelling  be  due  to  a 
subtegumentary  haemorrhage,  the  extravasated  blood  ought  to  be  lib- 
erated at  the  earliest  possible  moment.  If  it  be  due  to  an  infection, 
thorough  drainage  and  antiseptic  irrigation  will  limit  its  progress.  If 
pus  has  already  formed,  the  prompt  evacuation  of  this  material  is  the 
only  safeguard  against  extension  of  the  abscess  cavity. 

In  all  these  superficial  abscesses  the  operation  can  be  performed 
under  hypodermic  injections  of  cocaine  or  eucaine.  One  accustomed 
to  the  use  of  these  drugs  can  operate  upon  the  most  sensitive  patient  in 
such  conditions  as  this  without  any  more  pain  than  the  prick  of  a 
fine  needle.  Cocainization  having  been  established,  the  incision  should 
be  made  in  the  line  of  the  radial  folds.  These  abscesses  are  generally 
monolocular  and  circumscribed,  and  require  no  curetting  or  breaking 
down  of  necrotic  tissues  in  their  midst.  Simple  incision  and  drainage, 
accompanied  with  antiseptic  washings,  will  effect  a  rapid  and  satisfactory 
cure  in  the  large  majority  of  cases.  The  incision,  however,  must  extend 
from  the  highest  to  the  lowest  point  of  the  abscess;  diverticuli  in  acute 
abscesses  will  generally  heal  without  lateral  incisions.  The  cavity 
should  be  washed  out  twice  a  day  with  an  antiseptic  solution,  and  a 
small  gauze  drain  should  be  loosely  passed  into  the  wound.  Stretching 
of  the  sphincter  is  necessary  in  those  cases  in  which  the  incision  must 
be  carried  through  the  anal  canal  and  in  the  intramural  variety.  The 
latter  are  almost  the  only  abscesses  which  one  is  justified  in  opening 
by  incision  inside  of  the  rectum.  They  are  purely  submucous,  do  not 
involve  the  muscular  wall  of  the  rectum,  and  if  thoroughly  opened  and 
treated  by  drainage  and  irrigation  they  will  heal  without  the  formation 
of  fistula  or  other  complication.  The  important  point  is  to  leave  no 
pocket  at  the  lower  end  of  the  cavity.  This  is  likely  to  occur  when 
they  open  spontaneously.  Under  such  circumstances  one  will  find  some 
pus  present  in  the  rectum;  he  will  still  be  able  to  discover  tlie  soft, 
compressed  swelling,  and  through  a  speculum  can  see  the  dischai'ge 
exude  from  the  opening  when  he  presses  upon  the  mass.     It  is  needless 


PERIANAL   AND  PERIRECTAL  ABSCESSES 


331 


to  say  that  in  such  conditions  the  cavity  should  be  laid  open  to  its 
lowest  extent. 

Quiet  and  rest  in  bed  are  essential  to  the  most  satisfactory  results 
in  the  treatment  of  these  cases. 

Ischio-rectal  Abscesses. — These  form  a  typical  variety  of  what  is 
known  as  perirectal  abscesses.  It  is  generally  supposed  that  they  com- 
pose the  large  majority  of  perianal  and  perirectal  abscesses;  but,  as 
has  been  shown  by  Etchepare  (Des  abces  ischio-rectaux,  Th.  de  Paris, 
1894,  ISTo.  352),  these  fossse  are  the  seat  of  abscesses  in  less  than  18  per 
cent  of  the  total  number  of  cases  occurring  in  hospital  practice;  and, 
furthermore,  as  the  large  majority  of  sviperficial  perianal  abscesses  are 
treated  by  the  family  physician  and  are  never  seen  in  the  hospitals,  it 
is  reasonable  to  conclude  that  the  percentage  of  these  abscesses  is  even 
lower  than  Etchepare  claimed. 

They  are  generally  situated  around  the  rectum  itself  and  not  at  the 
margin  of  the  anus.  They  are  outside  of  the  muscular  and  aponeurotic 
layers  of  the  rectum 
and  anal  canal  and 
beneath  the  skin  and 
superficial  fascias 
(Fig.  110).  They  may 
be  limited  to  one 
side  of  the  rectum,  or 
may  occur  upon  both 
sides  simultaneously, 
becoming  connected 
posteriorly  through 
the  little  space  be- 
tween the  aponeu- 
roses of  the  levator 
ani  and  the  external 
sphincter  muscles. 
When  they  occur 
upon  one  side  of  the 
rectum    and    open 

spontaneously  or  are  incised  after  they  have  existed  several  days,  they 
are  very  likely  to  develop  upon  the  opposite  side  within  a  period 
of  four  or  five  days.  When  opened  they  do  not  exhibit  a  single 
large  cavity,  but  numerous  foci  containing  pus,  and  may  be  described 
as  multilocular  abscesses.  This  honeycomb-like  condition  of  the  abscess 
cavity  is  due  to  the  connective-tissue  network  which  divides  the  cellu- 
lar mass  into  spaces,  and  in  operating,  unless  great  care  is  exercised 
to  open  all  of  these,  the  pus  contained  in  them  will  burrow  or  infect  other 


Ym.  110.- 


-A,  ischio-rectal  abscess; 
abscess, 


B,  superior  pelvi-rectal 


332 


THE  ANUS,  RECTUM,   AND   PELVIC   COLON 


Fig.  111. 


-Bilateral  Ischio-rectal  Abscess  opexixg 
INTO  Kectum  Posteriorly. 


regions,  and  there  seems  to  be  no  limit  to  their  extent.  AVhen  both 
spaces  are  involved  and  connect  with  each  other  posteriorly,  they  form 
a  sort  of  dumb-bell  or  horseshoe-shaped  cavity.  This  communica- 
tion   is    not    uniformly    present.      The    infection    originating    in    an 

iniurv  of  the  anus  or 
lower  portion  of  the  rec- 
tum, through  which  the 
lymphatics  of  the  ischio- 
rectal fossa  become  in- 
volved, may  travel  upon 
one  side  more  rapidly  than 
it  does  upon  the  other,  and 
an  abscess  thus  develops 
u})on  this  side  some  days 
previously  to  its  develop- 
ment upon  the  other.  The 
author  has  opened  an  is- 
chio-rectal abscess  in  his 
office  on  one  day,  and 
with  careful  examination  failed  to  find  any  implication  or  even 
tenderness  upon  the  opposite  side,  and  yet  within  forty-eight  hours 
he  has  been  called  to  open  a  similar  abscess  at  this  point,  and  doing 
so  under  general  anaesthesia  has  searched  carefully  but  in  vain  for 
any  communication  between  the  two.  As  a  rule,  however,  where 
these  abscesses  develop  upon  both  sides  they  communicate  with  each 
other  posteriorly  through  the  foramen  already  mentioned,  and  ordi- 
narily in  such  cases  an  opening  will  be  found  in  the  posterior  commis- 
sure of  the  anus,  thus  constituting  a  true  horseshoe  fistula  (Fig.  111). 
This  little  perforation  of  the  mucous  membrane  at  this  point  indicates 
that  the  origin  of  the  abscess  and  fistula  has  probably  been  a  fissure  at 
this  seat,  through  which  the  lymphatics  of  the  ischio-rectal  fossa  have 
become  infected.  Abscesses  that  originate  in  the  ischio-rectal  fossa  may 
communicate  with  the  retro-rectal  space  or  vice  versa  by  perforation  of 
the  levator  ani,  and  thus  there  may  be  two  main  abscess  cavities  con- 
necting by  a  small  aperture  (Fig.  112).  Abscesses  of  the  pelvi-rectal 
spaces  sometimes  approach  the  surface  and  open  into  the  ischio-rectal 
fossae,  but  whether  those  of  the  ischio-rectal  fossa  ever  extend  up- 
ward along  the  side  of  the  rectum  sufficiently  high  to  involve  the 
superior  pelvi-rectal  spaces  and  infect  the  organs  with  which  they 
are  in  relationship,  is  difficult  to  say.  All  the  cases  in  which  abscesses 
involved  both  spaces  have  given  histories  which  led  to  the  belief  that 
the  abscess  was  originally  in  the  superior  space  and  had  involved  the 
ischio-rectal   fossa   by  extension  downward  through  the  fibers  of  the 


PERIANAL  AND   PERIRECTAL   ABSCESSES  333 

levator  ani  muscle^  either  separating  or  rupturing  tliem.  These  ab- 
scesses may  also  connect  with  submucous  abscesses  by  tracts  passing 
between  the  sphincter  muscles  (Fig.  113)  or  directly  through  them 
(Fig.  114). 

The  importance  of  all  this  lies  in  the  fact  that  if  these  superficial 
abscesses  may  inyolve  the  superior  spaces  it  lends  a  gravity  which  is 
not  ordinarily  attached  to  them. 

Etiology. — The  cause  of  these  abscesses  is  always  direct  or  indirect 
infection.  Puncture  wounds  and  injuries  from  sharp  bodies  within 
or  outside  of  the  rectum  may  carry  septic  germs  directly  into  the 
cellular  tissue  and  thus  produce  abscesses.     Ulceration  of  the  crypts  of 


Fl&.    112. — ISCHIO-KECTAL    AXD    EeTKO-EECTAL    AbSCESSES    COinR-NICATING    WITH    EaCH    OtHEE. 

The  rectum  is  dissected  off  and  drawn  forward. 


Morgagni  or  of  the  rectum  proper  may  result  in  ischio-rectal  abscesses 
through  direct  extension  of  the  ulcerative  process  or  by  infection 
through  the  lymphatics.  The  frequent  cause,  however,  of  ischio-rectal 
abscesses  is  infection  through  some  lesion  of  the  anal  canal.  Small 
fissures  or  wounds  in  this  region  are  very  liable  to  become  infected,  and 
as  the  infection  is  likely  to  affect  the  middle  IjTnphatics,  these  will  in- 
volve the  ischio-rectal  fossa?.  These  abscesses  frequently  follow  opera- 
tions for  fistula,  strictui-e,  and  hajmorrhoids.     In  these  cases  it  is  sup- 


334 


THE  ANUS,  RECTUM,   AND   PELVIC   COLON 


Fig.  113. 


-ISCHIO-RECTAL    AND    SuBMUCOrS    ABSCESSES    COM- 
MUXICATIXG. 


posed  that  tliey  are  metastatic.  The  author,  however,  has  observed,  in 
two  cases  in  which  ischio-rectal  abscesses  followed  operations  for  haemor- 
rhoids, that  upon  opening  the  abscess  cavity  there  escaped  a  considera- 
ble amount  of  decom- 
posed or  clotted  blood 
along  with  thin  sero- 
pus;  either  the  suppu- 
rative process  caused 
rupture  of  the  small 
vessels  and  hcT?mor- 
rhage  into  the  fossa, 
or  the  vessels  were 
ruptured  by  the  trau- 
matism necessary  to 
dilate  the  sphincters, 
and  infection  occurred 
later.  The  latter  view 
seems  more  rational. 
It  is  very  possible  that 
one  of  the  lower 
hgemorrhoidal  arteries 
which  ramify  in  this 
space  may  be  torn  by  this  stretching  process,  and  it  may  go  on  bleeding 
until  a  distinct  ha?matoma  is  formed  in  the  cellular  tissue,  and  this  may 
become  infected  through  the  lymphatics  leading  from  the  operative  field. 
In  the  cases  observed  the  symptoms  of  abscess  appeared  forty-eight  and 
sixty  hours  after  the  operation. 

Dilatation  of  the  sphincter  in  small  superficial  abscesses  at  the  anal 
margin  may  result  in  ischio-rectal  abscesses  by  squeezing  the  pyogenic 
germs  out  into  the  perirectal  tissues.  Contusions  and  prolonged  pres- 
sure, such  as  are  caused  by  long  horseback  or  bicycle  rides,  may  cause 
these  abscesses  either  by  obstruction  of  the  circulation  or  by  producing 
small  anal  lesions  which  become  infected. 

Stjmptoms. — As  a  rule  ischio-rectal  abscesses  develop  as  an  acute 
inflammatory  process;  the  patient  suffers  either  from  a  distinct  rigor 
or  a  feeling  of  chilliness  creeping  up  and  down  the  back  and  in  the  legs; 
these  are  followed  by  fever,  accelerated  pulse-rate,  headache,  and  at 
first  a  discomfort  about  the  rectum.  This  discomfort  changes  to  a  dull 
aching,  which  gradually  grows  into  an  acute  throbbing  pain.  In  the 
initial  stage  there  will  be  no  swelling  apparent  to  the  eye,  but  indura- 
tion may  be  felt  around  the  margin  of  the  anus  upon  one  side  or  the 
other.  Eedness  and  discoloration  may  or  may  not  be  present,  accord- 
ing to  the  depth  of  the  infection.     In  the  very  deep  cases,  in  order  to 


PERIANAL  AXD  PERIRECTAL  ABSCESSES 


335 


feel  the  induration  it  will  be  necessary  to  introduce  the  finger  well 
into  the  rectum  and  press  downward  and  outward  M'hile  deep  palpation 
is  made  with  the  other  hand  upon  the  external  surface.  One  will  gener- 
ally be  able  to  make  out  in  such  cases  a  distinct  circumscribed  mass, 
globular  and  more  or  less  fluctuating.  When  the  inflammation  has 
existed  for  some  days,  swelling,  tension,  and  redness  of  the  cutaneous 
tissues  about  the  margin  of  the  anus  will  appear.  Defecation  is  ex- 
tremely painful ;  the  patient  suffers  from  difficulty  in  urination,  or  may 
be  unable  to  urinate  at  all.  The  constitutional  disturbances  may  be- 
come very  grave  and  approach  a  type  of  true  septicgemia.  Sometimes 
the  perianal  area  assumes  an  erysipelatous  blush,  and  only  a  micro- 
scopic examination  of  the  blood  and  discharges  can  distinguish  between 
these  acute,  aggravated  cases  of  perirectal  cellulitis  with  circumscribed 
abscesses  and  true  erj^sipelas.  The  inflammatory  processes  may  sur- 
round the  entire  rectum  and  anus  and  extend  through  the  perinseum 
into  the  scrotum  or  inguinal  regions.  These  phenomena  only  occur  in 
extremely  septic  cases  or  those  in  which  the  treatment  has  been 
neglected.  If  opened  early  the  discharge  from  these  abscesses,  which 
are  then  small,  is  of  a 
creamy-white  or  dark- 
brownish  color.  Where 
the  abscess  has  been 
due  to  an  extravasation 
of  blood,  the  clot  may 
be  discharged  as  a 
whole,  or  it  may  appear 
as  disorganized  flocculi 
mixed  with  pus  and 
serum. 

Sometimes  the  pus 
is  thin  and  ichorous 
and  contains  necrotic 
shreds  or  fibrous  tissue, 
indicating  the  phleg- 
monous nature  of  the 
abscess.  Such  cases  are 
likely  to  be  followed  by 

general  septicsemia.  It  possesses  a  foetid,  gangrenous,  disgusting  odor; 
this  has  been  frequently  said  to  indicate  coimection  with  the  rectum, 
but  it  is  not  the  fact.  Many  abscesses  possess  this  peculiar,  faecal  odor 
and  have  no  connection  whatever  with  the  rectum. 

The  escape  of  gases  from  these  abscesses  when  opened  has  also  been 
thought  to  prove  their  connection  with  the  rectum.     This  is  also  an 


Fig-.  114. — ^Ischio-hectai,  A^-D   SuBinjCOUS  Abscesses  con- 

^"ECTED    BT    TeACT   THEOrGH    THE    MuSCLES. 


336  THE  AXUS,   RECTUM,   AND   PELVIC   COLON 

error.  In  fact  those  abscesses  which  have  a  connection  with  the  rectum 
do  not  contain  pent-up  gas.  When,  therefore,  an  ischio-rectal  abscess 
is  opened  and  gas  escapes,  it  is  quite  a  reliable  sign  that  it  has  no  con- 
nection with  the  gut  itself.  These  gases  are  due  to  bacterial  decomposi- 
tion which  takes  place  in  the  cavity.  When  an  abscess  has  developed 
upon  one  side  and  opens  spontaneously,  or  has  been  incised,  the  tempera- 
ture will  rapidl}'  subside  and  all  the  constitutional  symptoms,  together 
with  the  pain,  may  disappear  within  twenty-four  hours.  The  pains, 
however,  may  recur  upon  the  same  side  or  upon  the  opposite  side,  the 
temperature  and  constitutional  symptoms  all  reappear,  and  the  patient 
suffer  quite  as  much  as  in  the  first  attack.  These  symptoms  are  due 
to  the  development  of  another  abscess  in  one  of  the- small  compartments 
of  the  cellular  tissue  which  was  not  broken  down  in  the  first  operation, 
or  to  infection  upon  the  opposite  side.  The  appearance,  symptoms, 
and  diagnosis  of  this  condition  are,  of  course,  more  or  less  identical  with 
those  of  the  first  abscess. 

All  the  physical  and  local  symptoms  of  ischio-rectal  abscess  may 
occur  from  haemorrhage  into  the  spaces  which  never  become  infected. 
The  author  has  opened  what  appeared  to  be  a  small,  deep-seated  swelling 
of  this  kind  and  turned  out  several  hard  clots  with  some  blood  serum, 
but  not  a  drop  of  pus.  The  tension  and  pain  disappeared  at  ouce  and 
the  parts  healed  without  any  suppuration  whatever.  When  such  symp- 
toms occur  without  the  premonitory  constitutional  phenomena,  one  may 
anticipate  finding  this  condition  or  a  tubercular  process. 

Treatment. — All  surgeons  agi'ee  that  free  incision  at  the  very  first 
moment  that  induration  can  be  made  out  is  the  only  treatment  which 
is  justifiable  in  these  cases.  Cold  applications,  leeches,  hot  poultices, 
etc.,  have  long  since  been  found  to  be  useless  in  causing  resolution. 
They  may  delay  the  formation  of  the  abscess  and  destruction  of 
tissue  for  a  period  and  give  partial  relief  to  the  sufferer,  but  they 
never  abort  the  suppurative  process.  When,  therefore,  a  swelling  or 
circumscribed  induration  can  be  made  out  about  the  margin  of  the 
anus  in  non-s^-philitic  cases,  the  parts  should  be  cocainized  and  the 
induration  incised  whatever  its  depth.  Puncturing  with  aspirating 
needles  to  determine  the  presence  of  pus  is  not  advised.  It  is  not  an 
important  question  whether  pus  is  already  present  or  not;  the  object 
to  be  attained  is  to  furnish  a  free  outlet  through  the  shortest  and  most 
harmless  channel  to  the  inflammatory  products  of  the  affected  area. 
If  this  contains  only  a  clot  or  the  products  of  non-suppurative  inflam- 
mation, a  clean  cut  made  with  antiseptic  precautions  will  do  no  harm. 
Puncturing  with  a  needle  can  result  in  nothing  more  than  to  distribute 
the  septic  products  through  its  track,  and  furnish  no  drainage  unless 
subsec^uent  incision  is  made.     The  same  objection  holds  good  to  punc- 


PERIANAL  AND  PERIRECTAL  ABSCESSES  337 

ture  with  small  tenotomes.  Careful  dissection  should  be  made  down 
upon  the  indurated  mass  or  abscess  cavity  by  means  of  an  incision  wide 
enough  to  give  the  operator  a  full  view  of  what  he  is  doing,  and  furnish 
free  subsequent  drainage  to  the  discharge.  The  external  incision 
should  be  wider  than  the  widest  portion  of  the  abscess,  if  possible,  other- 
wise there  will  be  pockets  and  diverticuli  into  which  the  pus  will 
burrow.  The  incision  should  be  made  parallel  to  but  well  outside  of  the 
fibers  of  the  external  sphincter  muscle. 

After  the  abscess  is  opened  the  finger  should  be  introduced  into 
the  cavity  and  all  the  little  honeycomb-like  fossae  of  the  cellular  tissues 
should  be  thoroughly  broken  down  in  every  direction.  Experience 
teaches  one  the  difference  between  the  feeling  of  necrotic,  suppurating 
tissue  and  healthy  cellular  divisions;  it  is  these  necrotic  and  suppurating 
fossae  which  should  be  broken  down,  and  this  can  only  be  surely  done 
with  the  finger  itself,  because  curetting  with  sharp  steel  spoons  is  very 
likely  to  go  beyond  the  diseased  tissues  and  furnishes  no  indication  of 
the  condition  of  the  parts.  These  processes  ought  to  be  carried  on 
under  constant  irrigation  with  a  l-to-2,000  bichloride  solution.  Should 
there  be  considerable  oozing  or  haemorrhage  after  the  cavity  has  been 
emptied  thoroughly,  it  should  be  tightly  packed  with  gauze  for  the  first 
twenty-four  hours;  this  packing,  however,  should  be  removed  at  the  end 
of  this  time  and  only  a  light  gauze  or  rubber  drain  introduced  there- 
after, because  it  is  of  the  utmost  importance  that  the  walls  of  the 
abscess  cavity  should  be  allowed  to  approach  each  other  as  nearly  as 
possible  in  order  that  rapid  union  may  take  place. 

Where  the  abscess  involves  both  ischio-rectal  fossae  simultaneously 
or  successively,  the  question  of  how  to  operate  may  puzzle  the  inex- 
perienced. Simple  incision  will  empty  the  abscess  unquestionably,  but 
it  does  not  provide  for  the  communicating  tract  between  the  two  ab- 
scesses posteriorly,  when  such  exists.  Hartmann  states  that  under  such 
circumstances  he  does  not  open  the  abscesses  themselves,  but  opens 
the  tissues  posteriorly  between  the  coccyx  and  the  anus,  introducing 
drains  into  the  abscesses  upon  each  side.  The  abscess  may  be  opened 
by  moderate  incision  upon  one  side  and  by  free  incision,  extending  to 
the  posterior  commissure  of  the  anus,  upon  the  other  side,  thus  thor- 
oughly draining  this  posterior  fistulous  tract  in  both  directions,  and 
effect  good  results.  In  2  cases  in  which  there  was  a  fistulous  communi- 
cation with  the  anus  associated  with  bilateral  ischio-rectal  abscess,  com- 
paratively small  openings  were  made  in  the  anterior  horns  of  the  ab- 
scess and  small  wicks  of  silk  thread  were  passed  from  these  openings 
backward  into  the  wound  made  at  the  posterior  commissure  of  the 
rectum,  laying  open  the  fistulous  tract  from  the  skin  into  the  anus 
and  enlarging  the  communication  between  the  two  lateral  abscesses. 
22 


338  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

In  both  of  these  cases  the  cures  were  remarkably  rapid  and  exceed- 
ingly satisfactory,  being  unaccompanied  by  any  of  the  retraction  and 
infundibular  shape  of  the  anus  which  results  when  the  cavities  on 
both  sides  and  posterior  to  the  anus  are  laid  open. 

The  author  has  never  seen  faecal  incontinence  ensue  from  laying 
open  the  abscess  cavities  freely,  even  though  they  entirely  surrounded 
the  rectum.  The  objection  to  this  operation  is  that  it  results  in  re- 
traction of  the  anus,  and  leaves  a  deep  depression  between  the  folds 
of  the  buttocks  below  the  sphincter  muscle  in  which  faecal  material  is 
liable  to  be  caught,  and  makes  it  very  difficult  to  keep  thoroughly 
clean. 

Wlien  these  abscesses  open  spontaneously  into  the  rectum  or  anus, 
as  they  may  do,  they  constitute  internal  blind  fistula,  and  should  be 
treated  as  such.  The  question,  however,  arises  as  to  the  probability 
of  these  abscesses  resulting  in  fistula  after  the}'^  are  opened  externally. 
Some  writers  have  held  that  this  is  so  likely  in  cases  where  the  ab- 
scess approaches  very  closely  the  rectal  wall  it  is  advisable  in  all  such 
to  convert  them  into  fistulas  at  once,  and  operate  by  incision  of  the 
rectal  wall  to  the  height  of  the  deepest  portion  of  the  abscess.  Such 
practice  can  not  be  condemned  too  forcibly.  AVliile  a  certain  num- 
ber of  abscesses  will  result  in  perforation  of  the  rectal  wall  subse- 
quent to  their  incision,  such  consequences  by  no  means  justify  the 
practice  of  subjecting  a  patient  to  the  dangers  of  incontinence  and  pro- 
longed cicatrization  which  necessarily  follow  the  conversion  of  ischio- 
rectal abscesses  into  true  fistulous  tracts.  Where  no  pathological  open- 
ing into  the  rectum  or  anus  exists,  it  is  unjustifiable  to  make  such  an 
opening  surgically  for  the  treatment  of  perirectal  abscesses.  There  is 
reason  to  believe  that  the  large  majority  of  perforations  into  the  rectum 
after  the  opening  of  ischio-rectal  abscesses  are  due  to  imperfect  tech- 
nique in  operation.  The  thorough  but  gentle  dilatation  of  the  sphinc- 
ter muscles  in  every  case  of  perirectal  abscess  is  an  important  feature 
of  the  operation;  it  gives  the  patient  relief  from  whatever  muscular 
spasm  may  be  occasioned  by  the  perirectal  operation  and  inflammatory 
process;  it  removes  obstruction  to  the  passages  of  gas  and  fiscal  matter 
so  that  no  undue  pressure  may  be  placed  upon  the  thin  rectal  wall, 
which  has  lost  more  or  less  of  its  external  support  in  the  evacuation 
of  the  abscess;  it  prevents  a  spasmodic  contraction  of  the  rectal  wall 
and  allows  it  to  more  closely  approach  the  external  walls  of  the  abscess, 
thus  facilitating  rapid  granulation  and  the  closing  of  this  cavity.  This 
dilatation  should  always  be  made  after  the  abscess  has  been  evacuated: 
attempts  at  dilatation  before  the  abscess  is  opened  are  very  liable  to 
result  in  rupture  of  the  rectal  wall,  because  this  is  always  more  fragile 
than  the  overlying  skin.     Moreover,  the  pressure  and  traumatism  neces- 


PERIANAL  AND   PERIRECTAL  ABSCESSES  339 

sary  in  such  dilatation  are  likely  to  squeeze  the  pus  contained  in  the 
abscess  into  the  lymphatics^  dislodge  the  thrombi  in  these  vessels,  and 
cause  the  septic  process  to  extend  into  other  and  more  remote  areas. 
Therefore,  let  the  abscess  be  opened  freely,  its  partitions  be  broken  down 
and  washed  out  with  antiseptic  solutions,  and  after  this  let  the  sphincter 
muscle  be  thoroughly  dilated  before  the  wound  is  dressed.  With  a 
drainage-tube  in  the  wound  temporarily  and  a  Pennington  tube  or 
rectal  plug  in  the  rectum  in  order  to  facilitate  the  escape  of  gas  as 
well  as  to  hold  the  rectal  wall  in  close  apposition  with  that  of  the 
abscess,  a  fistula  may  be  avoided  and  a  rapid  healing  be  obtained  in 
such  cases. 

PROFOUND    ABSCESS 

In  the  review  of  the  anatomy  of  these  parts  attention  was  called 
to  the  retro-rectal  and  superior  pelvi-rectal-  spaces.  Clinically  these 
spaces  have  been  considered  as  one,,  and  they  are  called  the  superior 
perirectal  spaces.  Eecent  anatomical  studies  have  demonstrated  the 
fact  that  they  are  divided  into  three — two  antero-lateral  and  one  pos- 
terior. The  two  lateral  ones  have  been  denominated  by  Eichet  the 
"  superior  pelvi-rectal  spaces  ";  the  posterior  is  the  "  retro-rectal  space," 
which  occupies  all  the  region  between  the  rectum  and  the  anterior 
surfaces  of  the  sacrum  and  coccyx.  The  blood-vessels  ramifying  in  the 
retro-rectal  spaces  come  from  the  middle  and  lateral  sacral  arteries 
with  a  few  branches  from  the  inferior  mesenteric.  Those  in  the 
superior  pelvi-rectai  spaces  come  from  the  hj^ogastric  artery  and  are 
connected  with  the  general  circulation.  The  lymphatics  of  the  two 
spaces  are  also  comparatively  distinct;  those  in  the  retro-rectal  space 
develop  about  the  lower  posterior  portions  of  the  rectum  and  coccyx; 
while  those  in  the  anterior  spaces  originate  in  the  anterior  wall  around 
the  prostate,  the  neck  of  the  bladder,  the  uterine  organs,  and  connect 
with  the  iliac  plexus  and  the  lateral  trunks  of  the  lymphatic  system. 
With  such  distinct  anatomical  divisions,  vascular  supj)ly,  and  lymphatic 
distribution,  one  can  clearly  understand  why  a  distinction  is  made 
between  the  circumscribed  inflammations  in  these  two  areas  and  call 
them  retro-rectal  and  superior  pelvi-rectal  abscesses. 

The  interstitial  abscess  represents  a  class  occurring  at  more  or 
less  remote  points  from  the  rectum  itself  in  the  muscular  or  cellular 
tissues  of  the  buttocks  and  due  to  infection  carried  from  the  perirectal 
tissues  along  the  course  of  the  lymphatics  through  the  obturator  fora- 
men or  the  ischiatic  notch. 

Retro-rectal  Abscess. — This  variety  develops  in  the  cellular  space 
between  the  rectum  and  sacrum  above  the  attachments  of  the  leva- 
tor ani  (Fig.  115).     It  may  be  due  to  necrosis  of  the  bones  of  the 


340 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


pelvis,  the  sacrinn,  coccyx,  ileum,  or  bodies  of  the  vertebne;  it  may 
result  from  perforation  of  the  rectal  wall  by  sharp  foreign  bodies  in 
the  intestinal  canal  or  by  instruments,  such  as  bougies  or  syringe- 
tips.  One  of  the  most  frequent  causes  is  the  operation  of  posterior 
proctotomy  or  incision  of  strictures  unaccompanied  by  thorough  drain- 
age. Fistulous  tracts  outside  of  fibrous  strictures  of  the  rectum  may 
also  occasion  it.  Gummata,  the  caseation  and  breaking  down  of  tuber- 
culous lymphoid  nodules,  and  infection  by  propagation  along  the  lym- 
phatic channels  from 
ulceration  of  the  rec- 
tum above  the  ex- 
ternal sphincter  may 
all  cause  them. 

Quenu  and  Hart- 
mann  state  that  ab- 
scesses of  the  appen- 
dix may  extend  into 
this  space  and  thus 
open  into  the  rectum. 
The  appendix  being 
within  the  peritoneal 
cavity  and  often  ex- 
tending down  into  the 
pelvis,  it  appears  that 
such  abscesses  are 
much  more  likely  to 
invade  the  superior 
pelvi-rectal  than  the 
retro-rectal  spaces. 
The  author  has  seen 
one,  and  had  commu- 
nicated to  him  three 
instances  in  which 
such  abscesses  have 
opened  into  the  rec- 
tum either  spontaneously  or  by  rupture  during  an  examination  of  this 
organ.  The  cases  were  all  in  women;  they  simulated  true  pelvic  abscess, 
and  the  perforation  was  always  in  the  anterior  wall  of  the  rectum.  The 
appendicular  origin  was  proved  by  subsequent  operation.  While,  there- 
fore, it  is  possible  that  such  abscesses  may  penetrate  the  retro-rectal 
space,  from  these  facts  and  the  anatomical  relations  this  course  would 
appear  very  unlikely.  It  is  not  unusual  for  retro-rectal  to  follow  ischio- 
rectal abscesses  or  varicose  ulceration;  they  are  not  at  all  uncommon 


Fig.  115. — Retro-rectal  Abscess. 


PERIANAL   AXD    PERIEECTAL  ABSCESSES  341 

after  resections  of  the  rectiim^  and  tliey  mar  also  result  from  gimsliot 
TTounds  of  the  pelvis. 

Symptoms. — The  developnient  of  such  abscesses  is  always  obscure. 
They  are  not  usually  ushered  in  b}-  distinct  rigors  and  constitutional 
manifestations.  A  dull  aching  in  the  sacrum,  with  pelvic  weight  and 
sciatic  pains  associated  with  slight  elevation  of  temperature,  general 
malaise,  constipation,  with  or  without  pain  at  the  time  of  defecation, 
and  a  gradually  increasing  sallowness  of  the  skin  such  as  accompanies 
chronic  suppuration  elsewhere  in  the  body,  are  the  general  s^mijDtoms. 

Palpation  around  the  margin  of  the  anus  and  in  the  perinfeum 
does  not,  as  a  rule,  elicit  any  pain  or  induration.  Examination  of  the 
rectum  with  the  finger  may  sometimes  demonstrate  the  presence  of 
nodules  more  or  less  circumscribed  and  inflamed,  or  a  diffuse,  boggy  mass 
in  the  hollow  of  the  sacrum.  In  the  beginning  this  mass  will  not  be 
fluctuating,  tense,  or  painful,  but  as  the  suppuration  increases  the  ten- 
sion of  the  parts  becomes  more  marked,  and  partial  obstruction  of  the 
rectal  canal  with  dysuria  may  develop.  Eventually  the  abscess  may 
burst  spontaneously  into  the  rectal  cavity,  or  it  may  perforate  the 
levator  ani,  infect  the  ischio-rectal  fossae,  and  finally  open  on  the  skin. 

Where  the  retro-rectal  abscess  has  existed  for  some  time,  it  may 
burrow  between  the  fibers  of  the  levator  ani  muscle  and  develop  in  the 
wall  of  the  rectum  itself  a  submucous  abscess  such  as  has  been  found 
in  a  case  reported  b}-  M.  Quenu  (Quenu  and  Hartmann,  p.  146).  When 
these  abscesses  secondarily  invade  the  lower  areas  around  the  anus, 
constitutional  symptoms,  associated  with  pain  and  great  depression, 
always  ensue. 

An  interesting  case  of  this  kind  occurred  in  the  Polyclinic  Hospital 
in  1898. 

Abstract  of  history-: 

J.  P.,  aged  fifty-two,  janitor,  had  suffered  for  several  weeks  with  a  dull, 
aching  pain  in  his  back,  difficulty  in  movement  of  his  bowels,  and  gradually 
increasing  weakness.  Only  a  few  days  previously,  however,  he  had  his  first 
distinct  rigor.  This  was  followed  by  a  high  fever  and  acute  pains  in  the  buttocks 
and  around  the  margin  of  the  anus. 

"WTien  first  seen  the  whole  perianal  region  was  distended,  tense,  hard,  fluctu- 
ating, and  of  a  dark  violaceous  color  that  indicated  the  rapid  approach  of  gan- 
grene of  the  parts.  Apparently  it  was  a  case  of  diffuse,  septic  periproctitis. 
Incision,  however,  into  the  ischio-rectal  fossa  gave  issue  to  an  immense  quantity  of 
most  foetid  pus.  So  sickening  was  the  odor  from  this  discharge  that  several  of  the 
students  were  nauseated  and  compelled  to  leave  the  room.  After  evacuation  of  the 
ischio-rectal  cavity  it  was  found  that  pressure  through  the  rectum  toward  the  hol- 
low of  the  sacrum  occasioned  a  continuous  flow  of  pus  from  the  wound.  Search- 
ing the  cavity  with  the  finger,  a  small  opening  was  found  between  the  ischio-rectal 
fossa  and  the  retro-rectal  space.  This  o]iening  was  enlarged,  and  a  long  uterine 
probe  was  introduced  to  its  full  length  upward  over  the  promontory  of  the  sacrum 


342  THE  ANUS,  RECTUM,   AND   PELVIC   COLON 

without  reaching  the  upper  limits  of  the  abscess  cavity.  At  the  time,  the  author 
was  convinced  that  this  abscess  was  due  to  a  necrosis  of  one  of  the  bodies  of  the 
spinal  vertebrae,  and  gave  an  unfavorable  prognosis  with  regard  to  the  patient's 
recovery.  The  only  symptoms  contraindicating  such  a  prognosis  were  the  acute 
septic  phenomena  which  had  occurred  in  the  later  stages  of  the  disease.  Such 
symptoms  rarely  accompany  tubercular  abscesses  and  those  due  to  necrosis  of  bone. 
This  patient  made  an  uneventful  recovery  after  about  ten  weeks'  residence  in 
the  hospital.  The  time  between  the  first  chill  and  the  date  of  operation  was 
entirely  too  brief  for  such  extensive  burrowing  upward  to  have  taken  place,  and 
therefore  it  was  undoubtedly  a  case  of  retro-rectal  abscess  which  had  burst  through 
into  the  ischio-rectal  fossa  and  caused  an  acute  suppurative  process  there. 

Such  abscesses  may  also  burrow  outward  through  the  ischiatic  notch, 
forming  diverticuli  or  pockets  in  the  tissues  of  the  buttocks.  This 
course,  however,  is  very  rare.  Those  occurring  in  this  region  are  usually 
metastatic  or  interstitial  abscesses  due  to  propagation  by  the  lymphatics, 
as  stated  above. 

Treatment. — The  treatment  consists  in  thorough  drainage.  A  semi- 
circular incision  between  the  anus  and  coccyx  is  the  best  in  these  cases. 
After  thorough  evacuation,  the  cavity  should  be  washed  out  with 
peroxide  of  hydrogen  followed  by  l-to-2,000  bichloride  solutions.  Gentle 
curetting  of  its  walls  may  be  advisable  sometimes,  but  one  should  be 
careful  in  doing  this  laterally  and  anteriorly  that  he  does  not  penetrate 
the  superior  pelvi-rectal  spaces  or  the  rectal  cavity  itself.  Unless  one 
is  experienced  in  these  operations  he  had  better  desist  from  such  a  pro- 
cedure and  allow  nature  to  take  care  of  the  sloughing  tissues. 

After  washing  out  the  cavity  one  should  introduce  two  long  rubber 
drainage-tubes  and  maintain  them  in  position  by  suturing  them  to  the 
edges  of  the  skin  or  pinning  them  there  with  a  safety-pin.  Through 
one  of  these  tubes  an  irrigating  fluid  may  be  carried  in  while  it  is  dis- 
charged from  the  other,  and  thus  the  abscess  cavity  may  be  kept  entirely 
clean.  The  sphincter  should  always  be  stretched  after  the  abscess  is 
evacuated,  and  the  stools  kept  regular  but  not  loose.  No  packing 
further  than  that  necessary  to  check  the  first  oozing  of  blood  should 
be  used  in  these  cases.  It  prevents  drainage  and  delays  healing.  Tonics, 
good,  nourishing  diet,  and  such  specific  medication  as  seems  indicated 
should  be  employed.  It  is  also  a  good  plan  to  keep  these  patients  on 
their  feet  most  of  the  day,  as  this  facilitates  the  drainage  both  through 
gravitation  and  through  pressure  upon  the  parts  by  the  pelvic  and 
abdominal  contents.  Sitting  should  not  be  allowed  until  the  abscess 
has  practically  healed,  as  this  posture  interferes  with  the  circulation 
and  drainage  of  the  parts. 

Superior  Pelvi-rectal  Abscess. — Tliosc  are  not,  as  a  rule,  developed 
from  rectal  inflammations,  but  generally  arise  from  affections  of  the 
bladder,  urethra,  prostate,  uterus,  or  broad  ligament.     In  women  they 


PERIANAL  AND  PERIRECTAL  ABSCESSES  343 

are  ordinarily  termed  pelvic  abscesses,  and  arise  from  infectious  diseases 
of  the  generative  organs.  In  men  they  often  occur  as  the  result  of 
posterior  urethritis  or  inflanmiation  of  the  prostate,  and  simulate  ab- 
scess of  this  organ. 

Psoas  abscesses,  necrosis  of  the  bones  of  the  pelvis,  suppuration  of 
the  broad  ligament,  perinephritis,  vesiculitis,  and  appendicitis  may  all 
cause  a  collection  of  pus  in  the  superior  pelvi-rectal  spaces.  Abscesses 
may  also  occur  here  as  the  result  of  inflammations  or  injuries  in  the 
anterior  rectal  wall,  the  infection  being  carried  by  the  middle  lymphatics 
and  arrested  here  owing  to  the  sudden  bend  of  the  vessels  in  the  lower 
part  of  these  spaces.  Traumatism  from  childbirth  or  instrumentation 
of  the  uterus  or  prostatic  urethra,  operations  for  stone,  prostatectomy, 
and  uterine  tumors  have  all  been  known  to  produce  these  abscesses, 
but  the  chief  causes  are  inflammations  of  the  prostate,  seminal  vesicles, 
uterus,  and  broad  ligaments. 

Symptoms. — The  premonitory  symptoms  of  such  abscesses  are  those 
of  prostatitis,  vesiculitis,  and  posterior  urethritis  in  men,  and  the 
inflammatory  phenomena  of  pelvic  or  uterine  disease  in  women.  They 
are  often  mistaken  for  ovarian  and  tubal  abscesses  or  tumors  of  the 
broad  ligament. 

They  are  usually  ushered  in  by  chill,  fever,  accelerated  pulse-rate, 
deepj  aching  pain,  and  interference  with  the  urinary  functions.  Occa- 
sionally they  develop  in  a  slow,  insidious  manner  without  chill  and  with 
very  slight  fever.  Dysuria,  hsemorrhage  from  the  bladder,  and  even 
complete  obstruction  of  the  urine  due  to  pressure  upon  the  ureters  has 
been  known  to  take  place.  CEdema  of  the  scrotum  and  vulva  with  pains 
in  the  perinasum  and  testicles  are  also  sometimes  present.  Difficulty 
and  pain  in  defecation  are  not  marked  symptoms  in  the  early  stages. 

Where  the  inflammation  is  of  a  tubercular  type  all  of  these  symp- 
toms will  be  less  marked  and  more  slowly  progressive.  Where  it  is 
due  to  gonorrhoea,  as  it  often  is  in  both  sexes,  the  temperature  may 
rise  very  high  and  the  constitutional  symptoms  become  alarming.  The 
abscesses  have  a  tendency  to  burrow  upward  into  the  iliac  fossa  and 
outward  toward  the  abdominal  wall  rather  than  downward  toward  the 
peringeum  (Fig.  110,  B),  owing  to  the  greater  resistance  in  this  latter 
direction.  They  may  perforate  the  peritoneal  cavity,  causing  acute 
;septic  peritonitis  and  death  within  a  short  time.  Inflammation  may 
also  spread  to  this  membrane  without  perforation,  and  develop  either 
a  localized  or  general  peritonitis.  Perforation  of  other  organs,  such 
as  the  bladder  and  rectum,  may  result  at  any  time  during  their  course. 
The  discharge  of  large  quantities  of  pus  from  the  rectum  or  through 
the  urethra  accompanied  by  more  or  less  relief  from  the  feeling  of 
tension,   weight,   and   pain   within    the   pelvis,   would    indicate    this. 


34:4  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

Perforation  through  the  vagina  in  women  is  rare,  but  may  occur.  The 
diagnosis  of  superior  pelvi-rectal  abscess  rests  largely  upon  a  history 
of  diseases  and  symptoms  connected  with  the  genito-urinary  and 
reproductive  apparatus;  the  patient  rarely  gives  any  account  of  previ- 
ous rectal  disease;  perianal  and  perineal  palpation  only  elicits  a  deep 
tenderness  but  no  swelling  or  induration.  Digital  examination  of  the 
rectum  will  generally  elicit  a  tenderness  above  the  prostate  in  male 
patients  and  to  one  side  of  the  central  line.  In  females  the  abscess  is 
usually  high  up,  and  requires  a  long  reach  of  the  finger  in  order  to 
determine  its  existence.  Pain  upon  pressure,  induration,  and  thicken- 
ing of  the  rectal  wall  may  be  felt,  together  with  a  circumscribed  swell- 
ing, which  in  thin  people  may  be  outlined  by  the  finger  in  the  rectum 
and  palpation  of  the  abdomen  from  above.  \Anren  the  abscess  has 
existed  for  some  time  and  become  quite  tense,  it  may  extend  down- 
ward between  the  rectum  and  the  prostate,  enter  into  the  ischio-rectal 
fossae  by  perforating  the  levator  ani  muscle,  or  even  penetrate  the 
retro-rectal  space. 

The  diagnosis  is  not  difficult  in  these  late  stages;  it  is  only  in  the 
early  periods  of  inflammation  that  one  finds  it  hard  to  determine  the 
exact  nature  of  the  condition.  It  is  useless  to  insist  upon  the  impor- 
tance of  this  being  made  early  in  view  of  the  grave  complications  which 
may  result  from  delay.  The  fact  that  the  patient  has  only  sliglit  eleva- 
tion of  temperature  or  a  comparatively  slow  pulse-rate  does  not  eontra- 
indicate  the  presence  of  deep  pelvic  abscess.  Sometimes  they  develop 
a  low  grade  of  fever  with  typhoid  symptoms,  diarrhoea,  and  mental 
depression.  These  cases  have  been  mistaken  for  typhoid  fever  more 
than  once.  The  urinary  symptoms  often  mask  the  rectal  symptoms  in 
men,  and  patients  go  from  one  hospital  to  another,  having  sounds 
passed,  the  urine  drawn,  and  the  bladder  washed  out  for  acute  cystitis 
and  enlarged  prostate,  whereas  the  condition  is  due  to  pelvic  abscess, 
which  is  not  diagnosed,  if  indeed  a  rectal  examination  is  made  at  all. 
In  women  these  symptoms,  instead  of  being  referred  to  the  urinary 
apparatus,  are  generally  taken  to  indicate  an  inflammatory  condition 
of  the  uterine  organs,  and  vaginal  examination  is  soon  made  Gynaecolo- 
gists are  in  the  habit  of  making  rectal  examinations  in  order  to  cor- 
roborate the  information  obtained  per  vaginam,  and  the  result  is  that 
such  abscesses  rarely  escape  notice  in  this  sex.  In  men  they  are  situ- 
ated, as  a  rule,  anterior  to  and  at  one  side  of  the  rectum ;  they  may  be 
upon  a  level  with  or  Just  above  the  prostate.  In  women  they  are  liable 
to  be  more  upon  one  side  than  anteriorly,  because  the  pelvi-rectal 
spaces  are  practically  separated  in  front  by  the  close  union  between 
the  rectum  and  vaginal  wall  below,  and  because  the  lymphatics  which 
carry  the  infection  run  along  the  borders  of  the  broad  ligament  and 


PERIANAL  AND   PERIRECTAL  ABSCESSES  345 

are  therefore  distributed  upon  the  sides  more  than  anteriorly.  The 
general  course  which  such  abscesses  pursue  and  the  extent  to  which 
they  burrow  have  been  already  mentioned.  They  sometimes  entirely 
surround  the  rectum  and  destroy  all  the  cellular  tissues  between  the 
levator  ani  and  the  peritonaeum.  They  may  break  a  way  through  the 
levator  ani  muscle,  enter  the  ischio-rectal  and  retro-rectal  spaces,  and 
finally  make  for  themselves  outlets  at  some  portion  of  the  circumfer- 
ence of  the  anus.  When,  hoAvever,  one  comes  to  open  such  a  cavity 
or  to  examine  the  discharges  he  will  find  it  almost  impossible  to  de- 
termine the  origin  and  pathological  cause,  owing  to  the  fact  that  the 
abscess  has  remained  chronic  for  so  long  that  the  production  of  phago- 
cytes and  their  destruction  of  the  pathological  bacilli  often  render 
microscopic  examination  and  cultures  negative.  In  such  cases,  where 
great  destruction  of  tissue  has  taken  place  around  the  rectum,  the 
probability  of  absolute  restoration  of  the  functional  action  to  the  parts 
is  somewhat  remote.  Fibrous  and  cicatricial  deposit  are  likely  to  result 
in  stiffness  and  contraction  of  the  gut  wall,  which  it  is  very  difficult 
to  overcome. 

In  the  early  development  of  these  abscesses  it  may  be  almost  impos- 
sible to  diagnose  them,  although  the  general  symptoms  indicate  pus 
formation.  Where  the  surgeon  is  unable  to  make  out  the  collection 
by  combined  digital  touch  and  abdominal  palpation,  an  examination  of 
the  blood  may  show  a  marked  increase  of  white  blood-corpuscles,  and 
may  give  a  fairly  positive  indication  of  the  condition  with  which  he  has 
to  deal.  Examination  of  the  rectum  by  long  rectal  tubes,  and  even  soft- 
rubber  bougies,  is  contraindicated  in  cases  in  which  pelvic  abscesses  are 
suspected  on  account  of  the  danger  of  rupturing  the  wall  of  the  rectum 
and  thus  opening  the  abscess  into  it. 

Treatment. — The  treatment  of  this  condition  consists  in  evacuating 
the  pus  at  the  earliest  possible  moment  and  affording  the  cavity  a  free 
drainage. 

The  methods  of  evacuating  these  abscesses  are  not  so  easily  de- 
scribed. Ziegler  and  many  of  the  earlier  surgeons  advocated  opening 
them  through  the  rectal  wall.  Wliere  no  pathological  opening  in  the 
rectum  exists,  it  is  rarely  justifiable  for  a  surgeon  to  make  one.  A 
deep  dissection  through  the  perineum  to  find  and  evacuate  the  abscess 
cavity  is  the  proper  course.  The  rectum  may  be  dissected  away  from 
its  attachments  to  the  prostate  and  bladder  for  a  distance  of  2-|  inches 
in  order  to  reach  an  abscess  in  the  superior  pelvi-rectal  space  and  give 
free  drainage.  If  possible  the  surface  wound  should  always  be  equal 
to  the  widest  portion  of  the  abscess  cavity.  It  is  only  by  making  sucli 
incisions  that  diverticuli  or  pockets  can  be  avoided.  Deep  punctures 
with  small,  sharp  bistouries  are  likely  to  wound  blood-vessels  which 


34:6        THE  ANUS,  EECTUM,  AND  PELVIC  COLON 

can  not  be  seen,  they  may  penetrate  the  peritona3um,  they  leave  long, 
narrow  tracts  in  which  the  discharged  pus  causes  infection  and  sec- 
ondary abscesses,  and  drainage  is  never  satisfactory  through  them. 
Wide,  free,  open  dissection  to  whatever  depth  the  abscess  may  be,  is 
therefore  the  rule  in  this  class  of  cases.  Where  the  abscess  is  well 
defined  upon  one  side,  the  incision  may  be  made  upon  that  side  in  a 
line  parallel  to  the  fibers  of  the  external  sphincter,  but  well  removed 
from  the  anus.  Where  it  apparently  surroimds  the  anterior  rectum, 
the  incision  should  be  carried  upward  in  the  recto-iirethral  plane,  being 
careful  not  to  wound  the  urethra  or  to  invade  the  peritoneal  cul-de-sac. 
If  the  incision  should  extend  as  high  as  2^  to  3  inches,  the  surgeon 
should  carry  it  upward  by  dull  dissection  and  make  efforts  to  push  the 
peritoneum  above  by  the  finger  rather  than  by  the  use  of  a  knife. 

When  the  abscess  has  been  reached  and  the  pus  begins  to  be  dis- 
charged, a  long  tube  should  be  introduced  into  the  cavity  and  tJiorough 
irrigation  with  peroxide  of  hydrogen,  bichloride,  or  carbolic-acid  solu- 
tions should  be  carried  on  until  it  is  thoroughly  evacuated.  After  this 
the  finger  should  be  introduced  into  the  cavity,  and  as  far  as  possible 
the  extent  and  direction  should  be  examined.  Tearing  or  stretching 
of  the  opening  into  the  cavity  is  not  advisable,  because  the  tissues  are 
tender  and  one  never  knows  in  what  direction  they  will  give  way;  it 
may  be  into  the  peritoneal  cavity,  it  may  be  into  the  bladder,  or  it 
may  be  into  the  rectum.  Therefore  we  should  incise  the  wall  in  the 
direction  of  greatest  safety,  guiding  the  knife  or  scissors  with  the 
finger,  and  thus  widen  the  opening  into  the  abscess  cavity  without 
danger  of  invading  the  other  pelvic  organs.  After  the  abscess  has  thus 
been  evacuated  and  free  drainage  furnished,  the  sphincter  muscle 
should  always  be  thoroughly  stretched,  in  order  to  avoid  any  obstruc- 
tion to  the  passage  of  gas  and  fsecal  matters  which  might  add  an 
additional  strain  to  the  weakened  saeptum,  between  the  rectum  and  the 
abscess  cavity. 

The  curetting  of  such  abscess  cavities  is  rarely,  if  ever,  advisable. 
The  author's  experience  does  not  agree  with  that  of  Dr.  Kelsey,  who 
says  in  his  latest  work,  "  That  to  reach  pus  by  a  perineal  incision  would 
seldom  be  practicable  in  these  cases."  Any  perirectal  abscess  ivliich  can 
he  felt  hy  the  finger  in  the  rectum  can  be  reached  hy  perineal  dissection, 
and  should  he  so  reached  and  opened.  If  by  any  possibility  the  urethra 
or  bladder  has  been  opened  by  the  ulcerative  process,  the  conversion 
of  the  abscess  into  a  perineal  urinary  fistula  will  be  by  all  means  the 
safest  and  surest  road  to  cure. 

In  males  there  is  only  one  other  procedure,  and  that  is  the  opening 
of  the  abscess  through  the  rectum,  which  is  not  only  unsatisfactory 
from  the  point  of  view  of  drainage,  but  it  is  liable  to  leave  pockets 


PERIANAL  AND  PERIRECTAL  ABSCESSES  347 

and  burrowing  diverticuli,  and  if  there  is  perforation  of  the  urinary 
organs,  will  result  in  recto-vesical  or  recto-urethral  fistula.  Aside  from 
this,  it  only  opens  a  new  channel  for  infection  of  the  walls  of  the  abscess 
by  the  bacteria  of  the  intestinal  canal.  It  need  not  therefore  be  further 
considered. 

The  practice  of  introducing  long  aspirating  needles  through  the 
perineum  or  through  the  rectum  into  swellings  or  tumors  between  the 
rectum  and  the  bladder  or  prostate  is  objectionable  for  the  reasons 
that,  introduced  through  the  rectum,  the  pus  is  sure  to  follow  the  needle 
outward,  thus  necessitating  an  opening  into  that  cavity;  if  the  tumor 
proves  to  be  a  neoplasm,  the  needle  carried  through  the  mucous  mem- 
brane is  very  liable  to  infect  the  same  and  produce  an  abscess 
or  septic  condition.  If  introduced  through  the  perinasum  the  dangers 
of  wounding  the  peritoneal  pouch,  and  the  fact  that  pus  will  surely 
follow  outward  in  the  track  of  the  needle  if  an  abscess  is  present,  and 
infect  a  tract  which  it  may  be  impossible  to  absolutely  follow  in  dissect- 
ing down  upon  the  abscess,  thus  leaving  a  new  line  of  infection  which 
is  not  properly  drained,  are  sufficient  to  condemn  it.  Experience  and 
judgment  in  the  examination  of  these  cases  should  render  the  operator 
certain  enough  of  his  diagnosis  as  to  a  collection  of  fluid  in  any  case 
in  which  he  can  reach  the  swelling  with  his  finger,  and  whether  that 
collection  be  a  cyst,  an  extravasation  of  urine  or  blood,  or  a  collection 
of  pus,  perineal  incision  and  drainage  should  be  made  without  the 
blind  test  of  aspiration. 

As  to  drainage  in  these  cases,  a  rubber  tube  is  preferable  to  gauze. 
In  many  instances  gauze  wicks  have  been  introduced  into  the  abdomen 
after  operations  for  appendicitis,  and  into  abscess  cavities  about  the 
rectum  and  in  other  portions  of  the  body  for  drainage,  and  yet  when 
those  wicks  have  been  drawn  out  there  have  been  accumulations  of 
greater  or  less  quantities  of  pus  at  the  bottom  of  the  cavities,  which 
the  gauze  wicks  seemed  to  obstruct  rather  than  to  drain.  The  gauze 
drain  is  not  satisfactory  where  there  is  a  thick,  tenacious  pus.  Packing 
of  the  abscess  cavity  is  always  unadvisable.  The  walls  should  be  allowed 
to  come  as  closely  in  contact  as  possible.  Therefore  small  drainage- 
tubes  just  sufficient  to  keep  the  cavities  free  from  collections  of  pus 
are  best.  Frequent  irrigation  with  antiseptic  solutions  is  also  impor- 
tant. Sometimes  a  strong  solution  of  bichloride  of  mercury  (1  to  500) 
is  run  into  the  cavity,  and  this  is  washed  out  with  a  milder  solution 
(1  to  5,000)  immediately  thereafter.  If  the  wound  exhibits  a  sluggish 
tendency  and  the  abscess  does  not  heal  as  rapidly  as  the  general  condi- 
tion would  indicate,  it  will  sometimes  be  advantageous  to  inject  the 
cavity  or  swab  it  out  with  95-per-cent  carbolic  acid  or  pure  ichthyol.  In 
order  to  apply  the  latter  the  drainage-tubes  may  be  taken  out,  and  a 


348  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

narrow  strip  of  gauze  saturated  with  the  drug  introduced  into  the  cavity 
and  left  for  two  or  three  hours.  It  should  then  be  removed  and  the 
drainage-tubes  reintroduced. 

In  such  operations  the  sphincter  muscles  are  to  be  avoided,  but 
incision  of  the  levator  ani  is  not  only  unavoidable  but  desirable.  A 
simple  separation  of  the  fibers  may  evacuate  the  pus  which  is  situated 
Just  above  them,  but  as  soon  as  the  distention  produced  by  the  abscess 
has  disappeared  these  fibers  will  come  together  again,  and  tlius  the 
abscess  cavity  will  be  very  imjaerfectly  drained.  The  muscle  fibers, 
therefore,  should  be  cut  at  right  angles  in  order  to  prevent  this  re- 
contraction  and  interference  with  the  drainage. 

In  women  these  conditions  are  likely  to  be  very  chronic  and  to 
have  existed  for  long  periods  of  time  before  being  opened.  The  chronic 
pelvic  cellulitis  spoken  of  by  different  writers  is  often  associated  with 
collections  of  pus  which  neither  increase  nor  decrease  to  any  great 
extent,  but  which  remain  in  statu  quo  for  month  after  month,  the  con- 
nective-tissue deposit  thickening  and  increasing  about  it  all  the  while. 
It  is  through  this  process  that  stricture  of  the  rectum,  even  to  the 
extent  of  absolute  obstruction,  may  be  produced. 

Constipation  is  always  an  unfavorable  symptom  in  these  cases,  and 
the  longer  the  abscess  exists  the  more  marked  will  it  appear.  When 
pus  forms,  whether  in  the  tube  or  in  the  broad  ligament,  especiall}^  if 
the  superior  pelvi-rectal  spaces  are  involved,  it  should  be  evacuated 
through  the  vagina,  if  possible,  at  the  earliest  possible  moment  under 
the  strictest  antiseptic  precautions,  and  free  drainage  be  obtained. 

Where  the  abscess  points  upward  above  the  pubis  or  in  the  iliac 
fossa,  openings  may  be  made  in  these  regions  and  drainage  secured.  At 
the  same  time  healing  will  be  facilitated  if  the  abscess  is  given  a  de- 
pendent drainage  by  dissections  upward  through  the  perinaeum  or  vagina 
into  its  lowest  prolongation.  This  prolongation  can  be  determined  by 
the  use  of  a  full-sized  probe  introduced  through  the  abdominal  opening 
and  felt  with  the  finger  of  the  other  hand  introduced  into  the  rectum 
or  vagina. 

Diffuse  Septic  Periproctitis.^ — Before  the  days  of  antiseptic  surgery, 
surgeons  were  accustomed  to  meet  a  diffuse  form  of  inflammation 
involving  all  the  perirectal  tissues.  The  condition  generally  followed 
an  injury  to,  or  an  operation  upon,  the  rectal  wall.  It  has  been  de- 
scribed under  the  titles  of  perirectal  cellulitis,  septic  periproctitis,  and 
by  Boully  (Archiv.  gen.  de  med.,  Paris,  1879,  pp.  35,  162)  as  diffuse 
pelvic  cellulitis.  The  condition  is  characterized  by  an  acute  inflam- 
mation of  the  perirectal  tissues,  especially  those  of  the  retro-rectal 
and  ischio-rectal  spaces.  It  is  essentially  a  septic  process  of  very 
virulent  nature.     It  comes  on  at  any  time  from  a  few  hours  to  three 


PERIANAL   AXD   PERIRECTAL   ABSCESSES  349 

days  after  an  injury  to,  or  operation  upon,  the  rectum.  Strangely 
enough  a  case  of  this  disease  rarely  occurs  unless  perforation  of  the 
rectal  \vall  itself  has  preceded  it,  and  yet  in  its  destructive  processes 
the  walls  of  the  rectum  and  anus  are  rarely  involved.  The  inflamma- 
tion is  generally  confined  to  the  perirectal  tissues.  The  infiltration 
assumes  at  first  a  sort  of  semisolid  condition,  changing  later  to  a  sero- 
purulent  discharge  when  the  tissues  are  laid  open.  The  inflammatory 
process  may  extend  ujDward  and  forward,  involve  all  the  pelvi-rectal 
spaces,  and  may  invade  the  peritonaeum  through  extension,  osmosis  of  the 
septic  agents,  or  by  absolute  perforation.  In  the  first  instance  the 
peritonitis  will  be  of  an  intense  septic  type,  or  ultraseptic  as  described 
by  Quenu,  unaccompanied  by  any  great  adliesions  between  the  ab- 
dominal organs. 

Symptoms. — The  patient  does  not  usually  suffer  from  a  distinct 
rigor,  but  at  a  period  somewhere  between  a  few  hours  and  three  days 
after  the  operation  upon  or  injury  to  the  rectum,  a  creeping  chilliness 
comes  on  succeeded  by  accelerated  pulse,  high  temperature,  headache, 
brown-furred  tongnie,  and  sometimes  severe  vomiting.  The  pain  in 
the  wound  increases  greatly,  with  a  sense  of  fulness  and  weight  in  the 
sacral  region;  the  discharges  change  to  a  grayish,  bloody,  foetid  char- 
acter, and  the  perirectal  tissues  assume  a  bright-red,  tense,  and  shining 
appearance.  The  mucous  membrane  of  the  rectiun  and  anus  remains 
unchanged  or  becomes  oedematous  and  swollen.  Great  weakness  and 
depression  follow  rapidly  upon  this  condition,  and  the  patient  is  some- 
times seized  with  an  exliausting,  liquid  diarrhoea.  The  constitutional 
S}Tnptoms  are  those  of  general  sepsis,  very  closely  resembling  that  type 
known  as  puerperal  fever.  All  the  perineal  and  inguino-crural  tissues 
may  be  involved  in  the  process.  Difficulty  of  urination,  even  suj^pres- 
sion  of  the  urine,  may  complicate  affairs.  Complete  loss  of  appetite 
and  inability  to  retain  food  are  ordinarily  present.  During  the  course 
of  the  disease  septic  endocarditis  or  pericarditis  may  develop,  thus 
hastening  the  end.  Unless  checked  by  treatment  the  disease  runs  its 
course  and  ends  in  death  from  the  second  to  the  tenth  day. 

Treatment. — The  treatment  is  one  of  prevention  rather  than  cure. 
It  is  a  disease  which  should  not  occtir  at  the  present  day.  Of  course 
there  may  be  cases  in  which  accidental  injuries,  such  as  puncturing 
wounds,  may  invade  the  perirectal  tissues  and  thus  give  access  to  the 
virus,  but  such  cases  are  so  rare  that  one  need  hardly  consider  them. 
The  whole  secret  of  prevention  lies  in  antiseptic  precautions  and  free, 
wide  drainage  in  all  operations  about  the  rectum.  The  operations 
which  are  more  likely  than  any  other  to  be  followed  by  such  a  complica- 
tion are  those  of  proctotomy  for  stricture  or  resection  of  the  rectum 
for  tumors.     If,  however,  the  disease  should  occur  notwithstanding 


350  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

pro})er  ^urgital  precautions,  the  treatment  consists  in  bold  incisions  into 
all  the  swollen  and  inflamed  tissues,  followed  by  frequent  antiseptic 
irrigation  with  the  application  of  heat  in  the  interim  in  order  to  pro- 
mote the  circulation  and  prevent  the  occurrence  of  gangrene  in  the 
parts.  Where  the  symptoms  of  general  sepsis  are  ver}-  marked,  the 
injection  of  antistreptococcus  serum  may  be  of  advantage. 

It  has  been  suggested  also  in  such  cases  that  saline  infusions  into 
the  veins  will  result  in  the  destruction  of  the  bacilli  in  the  blood  and 
in  sustaining  the  strength  of  the  patient  until  the  septic  depression 
has  passed  away.  In  instances  in  which  this  has  been  done  in  very 
late  stages,  death  followed  in  due  time;  experience,  therefore,  does 
not  justify  the  statement  that  this  procedure  will  be  of  any  practical 
benefit.  Xo  drugs  have  any  particular  effect  upon  these  septic  condi- 
tions. In  the  light  of  modern  therapeutic  researches,  administering 
carbolic  acid  in  large  doses  might  possibly  be  of  some  benefit.  It  has 
been  demonstrated  that  this  drug  can  be  administered  in  doses  of  from 
3  minims  in  children  to  12  minims  in  adults,  every  three  hours,  with- 
out the  production  of  toxic  symptoms  except  in  cases  with  personal 
idiosyncrasies.  It  does  seem  to  have  some  bactericidal  influence  in 
such  microbic  diseases  as  whooping-cough,  pneumonia,  and  typhoid 
fever.  It  might  therefore  be  advisable  to  administer  it  in  septic  peri- 
proctitis. Salol  accompanied  with  strychnine  or  quinine  will  be  of  use 
to  control  the  bodily  temperature,  while  it  is  at  the  same  time  an 
intestinal  antiseptic.  The  main  reliance,  however,  will  be  upon  the 
frequent  antiseptic  irrigations  and  repeated  early  incisions  into  all  the 
tissues  involved. 

Idiopathic  Gangrenous  Periproctitis. — Under  the  title  of  idiopathic 
gangrenous  cellulitis,  Furneaux  Jordan  (Brit.  Med.  J.,  Jan.  18,  1879, 
p.  73)  has  described  an  unusual  type  of  perirectal  inflammation.  It 
consists  in  a  slowly  extending  cellulitis  unattended  by  much  swelling 
and  pain.  It  develops  usualh'  without  any  previous  injury,  but  may 
follow  surgical  operations  about  the  rectum.  In  its  general  aspect  it 
resembles  ver}'-  much  the  condition  seen  in  urinary  infiltration  of  the 
perina?um.  It  occurs,  as  a  rule,  in  large,  stout,  well-preserved  individuals 
and  in  active  and  excitable  men  given  to  heavy  eating  and  drinking: 
as  Jordan  says:  "In  men  sufficiently  well-to-do  to  indulge  at  will,  and 
who  firmly  believe  that  excessive  work  needs  excess  of  victuals  and  liquor; 
in  men  who  are  indifferent  to  weather  and  have  been  notably  exposed 
to  cold  and  wet." 

The  disease  begins  on  the  level  of  the  anus,  or  sometimes  in  the 
deeper  tissues.  It  progresses  very  rapidly,  and  there  seems  to  be  no 
limit  to  its  extent.  Gibbon  (London  Lancet,  1890,  vol.  i,  p.  7-17)  de- 
scribed a  case  in  which  the  process  extended  to  the  scrotum  and  entirely 


PERIANAL  AND  PERIRECTAL  ABSCESSES  351 

destroyed  it.  "Wyman  (American  Lancet^  Detroit,  March,  1892,  p.  244) 
has  reported  a  case  in  which  the  whole  perinEeiim  and  skin  over  the  but- 
tocks were  rapidly  destroyed  by  the  gangrenous  j^rocess.  Cases  have  also 
been  reported  b}-  Gerster  and  Kelsey  in  this  country,  but  the  most  exten- 
sive and  remarkable  one  is  that  related  by  Quenu  and  Hartmann  {op.  cit., 
137).  This  was  the  case  of  a  large,  strong  man,  a  heav}^  eater  and 
drinker,  who  was  seized  with  pains  about  the  region  of  the  anus  with- 
out any  known  cause ;  a  rigid  tumefaction  and  redness  of  the  area  about 
the  anus  and  perina?um  followed,  extending  between  the  scrotum  and 
the  thigh  upward  into  the  iliac  region  over  the  abdominal  surface,  even 
to  the  axillary  region.  Great  phlegmonous  infiltration  with  blisters, 
gangrenous  ^^laques,  and  the  development  of  gas  in  the  two  ischio-rectal 
fossffi  existed.  Posteriorly  the  infiltration  passed  across  the  sacrum. 
The  urinary  apparatus  in  this  case  remained  normal.  The  tongue  was 
red  and  dry,  and  the  temperature  reached  40°  C.  Aft^r  about  three 
months'  treatment,  with  frequent  incisions  and  drainage  of  the  involved 
areas,  this  patient  recovered. 

Etiology.— Thus  far  no  satisfactory  etiolog}"  has  been  suggested  for 
this  disease.  In  Gerster's  case  there  existed  a  diabetic  glycosuria,  and 
he  suggested  the  possibility  that  it  caused  the  condition.  In  the 
other  cases  reported  no  such  complication  has  been  observed.  Dun- 
glison,  adopting  the  term  of  Fuchs,  described  it  under  the  title  of 
proctocace.  According  to  Fuchs  it  is  a  common  condition  in  Peru 
(Quito  and  Lima),  in  Brazil,  and  on  the  Honduras  and  Mosquito  coasts. 
It  is  called  by  the  Portugiiese  "  bicho  "  and  "  bicho  di  culo.'^  In 
Quito  it  is  termed  "  mal  del  valle "  on  account  of  its  prevalence  in 
the  valleys.  It  is  also  known  in  Africa,  where  it  is  called  "  bitios  de 
kis."  From  its  frequency  in  these  regions  one  would  judge  that  climate, 
soil,  and  modes  of  life  had  something  to  do  with  its  production.  It 
has  been  attributed  to  the  use  of  decomposed  foods  and  excessive 
indulgence  in  condiments  and  spices.  On  the  contrary,  all  the  cases 
seen  by  Jordan  occurred  in  cold  weather  and  in  the  high  table-land 
of  mid-England,  and  no  case  has  been  reported  in  the  female  sex.  It 
seems,  therefore,  that  climate  can  not  account  for  it. 

Symptoms. — The  disease  comes  on  with  a  chill  followed  by  high  fever 
and  great  mental  and  constitutional  depression.  There  is  some  pain 
in  the  neighborhood  of  the  anus ;  the  skin  is  red  and  brawny,  the  epi- 
thelium elevated  and  covered  with  small  phlyctipnas,  which  soon  break 
down  and  leave  black  gangTenous  masses  which  discharge  an  ichorous 
fluid  instead  of  pus.  The  chief  characteristics  of  the  disease  are  its 
rapid  extension  and  its  tendency  to  light  up  again  and  invade  other 
tissues  after  it  has  once  been  apparently  checked.  Invasion  of  the 
ischio-rectal  and  superior  pelvi-rectal  spaces  and  thus  upward  into  the 


352  THE  AXUS,   RECTCM,    AND   PELVIC   COLON 

peritona'uni  is  its  common  course.  It  may  enter  the  retro-rectal  space, 
passing  out  through  the  obturator  foramen  and  invade  the  subtegu- 
mentary  tissues,  as  in  one  case  described  by  Jordan.  Wherever  the 
peritonaeum  becomes  involved  death  rapidly  ensues.  The  temperature 
runs  very  high,  the  tongue  is  dr}'  and  red,  and  the  whole  condition  is 
characterized  by  great  adynamia.  Even  after  free  incisions  have  been 
made  in  the  inflammator}-  mass  the  discharge  does  not  assume  the 
nature  of  pus,  but  rather  a  sanious  ichor  of  a  most  putrid  nature.  The 
gangrenous  process  is  self-limited.  If  the  patient  does  not  succumb 
to  sepsis  and  exhaustion  during  the  early  periods  of  the  disease,  it  will 
reqiiire  the  utmost  skill  and  perseverance  to  maintain  his  strength 
through  the  chronic  process  of  getting  rid  of  the  large  necrotic  masses 
which  may  be  accompanied  with  frequent  haemorrhages,  any  one  of 
which  may  bring  on  the  end. 

Treatment.-^The  treatment  of  this  condition  consists  in  early  and 
repeated  incisions  through  all  the  gangrenous  tissues  in  whatever  neigh- 
borhood they  may  be,  followed  by  antiseptic  irrigation  and  hot  anti- 
septic poultices.  Wliile  these  incisions  do  not  give  vent  to  any  cir- 
cumscribed collections  of  pus  or  ichor,  they  open  the  cellular  channels 
for  the  oozing  out  of  the  oedematous  collection  in  the  necrotic  masses, 
and  thus  relieve  the  tension  and  prevent  to  a  certain  degree  the  absorp- 
tion of  the  products  of  decay. 

Owing  to  the  fact  that  the  blood-vessels  themselves  frequently  re- 
main intact,  such  incisions  may  be  accompanied  with  dangerous  hsemor- 
rhages.  Jordan  mentions  an  instance  of  this  kind  in  which  the  ingenuity 
of  the  attending  physician  was  greatly  exercised  in  order  to  control  the 
bleeding.  He  finally  succeeded  in  doing  so  by  the  introduction  of  a 
Barnes's  dilator  into  the  rectum,  and  distending  this  organ  so  as  to 
produce  sufficient  pressure  upon  the  parts  to  control  the  haemorrhage. 

Ligatures  are  not  likely  to  prove  successful,  as  the  blood-vessels  are 
so  brittle  and  altered  that  they  would  likely  cut  through.  Firm  pres- 
sure is  the  most  reliable  means  of  controlling  the  flow. 

General  stimulation  together  with  hypodermoclysis  is  necessary,  and 
all  those  therapeutic  and  dietar)^  resources  for  the  maintenance  of 
strength  in  adynamic  diseases  should  be  taken  advantage  of.  In  the  large 
majority  of  instances  the  disease  results  fatally  sooner  or  later  from 
septic£emia  or  general  exhaustion. 


CHAPTEE   XI 


FISTULA 


The  Latin  word  fistula  signifies  a  pipe  or  reed,  and  has  been  applied 
to  this  disease  on  account  of  the  occasional  reed-like  shape  of  the  tracts 
and  the  passage  of  air  through  them.  It  is  a  misnomer,  however,  as  the 
large  majority  of  fistulas  are  tortuous,  very  irregular  in  shape,  and  gases 
do  not  pass  through  them. 

Definition. — Ano-rectal  fistula  may  be  defined  as  any  unnatural 
channel  extending  from  the  shin  or  muco-cutaneous  tegument  about  the  anus, 
or  from  the  mucous  memiratie  of  the  rectum  into  or  through  the  surround- 
ing tissues. 

The  essential  characteristic  of  the  disease  is  chronicity.  A  freshly 
opened  abscess,  either  external  or  internal  to  the  rectum,  forms  a  sinus, 
but  one  which  may  heal 
completely  in  a  short  time; 
unless  it  has  both  an  ex- 
ternal and  internal  open- 
ing it  would  not  be  termed 
a  fistula  until  it  had  shown 
no  tendency  to  heal  for  a 
considerable  period.  It 
would  save  confusion  if 
the  term  were  confined  to 
that  type  ordinarily  known 
as  the  complete  variety. 
Under  the  accepted  no- 
menclature, however,  every 
chronic    abscess    cavity    is 

a  fistula.     Accordingly,  they  are  broadly  classified  as  inccmplete  and 
complete. 

Classification. — Incomplete  Fistula. — This  variety  embraces  all  those 
cases  which  open  on  one  surface  only.  When  the  opening  is  outside  of 
the  ano-rectal  line  it  is  called  blind  external  fistula  (Fig.  116),  and  when 
it  is  within  the  rectum,  blind  internal  fistula  (Fig.  117). 

23  353 


Fig.  116. — Blind  Exteenal  Fistulas. 


354 


THE  AXUS,   RECTUM,   AND   PELVIC   COLON 


Complete  Fistula. — This  type  includes  all  those  cases  in  which  there 
is  both  an  external  and  internal  opening,  and  a  pervious  tract  from  the 

surface  outside  of  the  anus 
into  the  cavity  of  the  anus 
or  rectum  (Fig.  118). 

Fistulas  are  also  classi- 
fied according  to  the  tis- 
4  sues  involved.  Those 
which  simply  pass  under- 
neath the  skin,  muco-cuta- 
neous  or  mucous  tissues, 
are  termed  suhfegianen- 
tary,  submuco-cutaneous,  or 
submucous  (Figs.  117,  A, 
119).  Those  which  pass 
outside  of  the  muscular 
apparatus  of  the  rectum  or 


Fig.  117. — Blind  Internal  Fistulas. 
A,  subtegumentary  ;  B,  subaponeurotic. 


anus  are  called  siibmuscular  or  subaponeurotic  (Figs.  116,  118). 

In  addition  to  these  divisions  there  are  also  simple,  complex,  and 
complicated  fistulas.  The  simple  fistula  consists  in  a  sinus  tract  lead- 
ing from  the  skin  or  mucous  membrane  into  the  perirectal  tissue,  or 
a  complete  tract  leading  directl}^  from  an  opening  in  the  skin  to  one 
in  the  mucous  membrane.  The  complex  variety  consists  in  variations 
of  these  conditions,  such 
as  wide  burrowing  and 
great  tortuosity  of  the 
tract,  the  existence  of  two 
or  more  openings  on  the 
skin  with  one  in  the  rec- 
tum, or  two  or  more  in  the 
•rectum  with  one  upon  the 
skin.  By  the  term  compli- 
cated fistula  is  meant  those 
cases  which  are  compli- 
cated by  necrosis  of  the 
bones,  or  hj  connections 
with  other  organs,  such  as 
the  bladder,  urethra,  va- 
gina, and  uterus.  The  lat- 
ter require  special  consideration  and  peculiar  treatment.  It  is  there- 
fore considered  wise  to  study  them  apart  from  the  ordinary  ano-rectal 
fistulas. 

Finally,  fistulas  may  be  classified  according  to  their  pathological 


Fig.  118.- 


-Complete  Subaponecrotic  Fistulas, 
Showing  irregular  tracts. 


FISTULA 


555 


causes  into  specific  and  non-specific  types.  The  specific  t}q3es  are  tliose 
due  to  tuberculosis,  carcinoma,  and  syphilis;  the  non-specific  are  those 
due  to  simple  inflammatory  processes  or  injuries.  On  account  of  the 
tuberculous  variety,  this  classification  is  of  great  importance. 

Feequexcy  of  Fistula. — The  frequency  with  which  fistula  occurs 
in  comparison  with  other  rectal  diseases  may  be  gathered  from  the  statis- 
tics of  special  hospital  services.  In  St.  Mark's  Hospital,  London,  as 
quoted  by  AUiagham,  out  of  4,000  rectal  cases,  1,057  persons  suffered 
from  fistula  and  196  from  abscesses,  of  which  151  subsequently  became 
fistulas.  One  may  therefore  practically  state  that  1,208  out  of  4,000 
cases,  or  nearly  one-third  of  all  rectal  diseases,  were  fistulas.  These 
statistics  are  taken  from  the  walking  cases,  whereas  the  records  of  the 
hospital  show  that  two-thirds  of  those  operated  upon  in  this  Mecca  for 
these  sufferers  were  cases 
of  this  disease. 

In  examining  the  re- 
ports •  of  the  general  hos- 
pitals in  this  city  it  is 
found  that  over  one-half 
of  the  cases  operated  upon 
for  rectal  diseases  in  five 
years  were  fistulas.  In  the 
author's  service  at  the 
Polyclinic  Hospital  the 
percentage  is  not  so  high; 
this  may  be  attributed  to 
the  fact,  however,  that  all 
the  inflammatory  and  ca- 
tarrhal conditions  of  the  lower  intestine  are  treated  in  this  clinic,  where- 
as a  number  of  fistulas  fall  into  the  hands  of  general  surgeons,  and 
therefore  the  proportion  is  reduced.  Even  under  these  circumstances 
this  condition  comprises  one-fifth  of  all  rectal  diseases. 

With  regard  to  the  proportionate  frequency  of  the  different  varie- 
ties it  may  be  said  that  complete  fistula  comprises  about  70  per  cent, 
blind  external  fistula  about  20  per  cent,  and  blind  internal  about  10  per 
cent  of  the  cases  recorded. 

As  to  the  frequency  of  simple  and  complex  fistulas  the  experience 
of  surgeons  differs  greatly.  If  we  consider  only  those  cases  complex 
which  have  more  than  one  opening  either  externally  or  internally,  then 
the  complex  variety  will  only  comprise  about  5  per  cent  of  the  cases 
seen.  On  the  other  hand,  if  we  consider  those  cases  complex  which 
consist  in  tortuous  tracts  burrowing  in  different  directions,  or  partially 
surrounding  the  anus,  the  proportion  between  the  two  will  be  materi- 


FlG.    119. SrBTEGTISIEJJTAET   FlSTCLAS. 

A,  blind  external ;  B,  complete. 


356  THE  ANUS,   RECTUM,   AND   PELVIC  COLON 

ally  altered;  in  fact,  the  majority  of  chronic  fistulas  are  complicated  hy 
some  such  diverticuli  or  burrowing  tracts.  It  would  complicate  matters 
to  consider  all  such  cases  complex;  therefore  it  is  better  to  confine  the 
term  to  those  cases  which  have  multijile  openings  upon  one  surface  or 
the  other. 

Etiology. — With  few  exceptions  all  fistulas  originate  in  abscesses. 
They  may  occasionally  be  produced  by  penetrating  wounds  which  ex- 
tend from  the  external  surface  into  the  rectal  cavity.  Two  cases  of  this 
kind  have  come  to  the  notice  of  the  writer:  in  one  the  patient  was 
thrown  from  a  wagon  and  fell  upon  the  metallic  stem  of  an  umbrella, 
which  punctured  the  skin  about  1  inch  from  the  anus,  and  passed  through 
into  the  rectum  1^  inch  above  the  anal  margin;  in  the  other  the  condi- 
tion was  caused  by  squatting  down  upon  the  sharp  stump  of  a  weed. 
This  case  has  been  referred  to  in  the  chapter  on  accidents  and  injuries. 
In  each  case  complete  fistula  resulted. 

Gunshot  and  bayonet  wounds  may  produce  them  (Med.  and  Surg. 
History  of  the  War  of  the  Eebellion).  Ordinarily  intermediary  abscesses 
occur  in  such  cases,  but  always  there  is  infection  which  gives  to  the 
wound  the  chronic  characteristics  which  constitute  fistula.  In  general 
one  may  say  that  abscess  or  destructive  ulceration  always  precedes 
fistula.  Whatever  produces  these  conditions  may  also  cause  it.  Wounds, 
injuries,  tuberculosis,  syphilis,  stricture,  etc.,  are  therefore  etiological 
factors.  Ulceration  and  burrowing  from  the  base  of  mucous  diverticuli 
in  the  rectum  and  pelvic  colon  are  said  by  Cruveilhier  (Anat.  path,  gene- 
rale,  Paris,  1849,  t.  i,  p.  594)  and  Frangou  (Th.,  Lyon,  1883-'84,  No.  199) 
to  be  the  point  of  departure  for  internal  blind  fistulas.  Perforating 
tubercular  ulcers  of  the  rectum  have  long  been  considered  the  originat- 
ing cause  of  the  disease.  Pathological  researches,  however,  fail  to  con- 
firm this  view,  which  has  been  particularly  elaborated  by  Koenig  (Lehr- 
buch  speciellen  Chirurg.,  Berlin,  1899,  vol.  ii,  p.  539).  If  this  were 
the  case,  there  would  be  usually  other  ulcers  around  the  internal  opening 
of  the  fistula,  as  tubercular  ulcers  of  the  rectum  are  rarely  single.  As  a 
matter  of  fact,  in  the  large  majority  of  fistulas,  ulcers  of  the  rectum  are 
not  present  except  at  the  fistulous  opening.  Thus,  in  41  cases  of  tuber- 
cular fistula  examined  by  M.  Hartmann  (Eevue  de  chirur.,  1894)  there 
were  only  2  cases  in  which  there  existed  ulcerations  of  the  rectum  sepa- 
rate from  the  internal  opening  of  the  fistula.  Moreover,  if  the  fistula 
originated  in  a  perforating  ulcer  of  the  rectum  it  would  always  assume 
the  type  of  a  blind  internal  fistula  at  first,  and  present  the  symptoms 
of  such,  but  this  is  not  the  rule  either  in  the  simple  or  tiibercular  types. 
The  discharge  from  the  rectum  does  not  often  occur  imtil  after  the 
symptoms  of  abscess  have  existed  for  some  days — in  short,  the  ulcer 
develops  after  the  abscess. 


FISTULA  357 

The  question  now  arises^  If  they  all  originate  in  abscesses,  why  do 
not  these  heal,  and  why  the  ehronicity  which  constitutes  fistula?  Many 
theories  and  conditions  have  been  evoked  in  the  explanation  of  this  fact. 
It  is  easy  to  understand  why  a  complete  fistula  does  not  close  on  account 
of  the  constant  passage  of  fsecal  matters  and  gases  through  its  tract,  thus 
preventing  by  mechanical  action  the  agglutination  of  its  walls.  More- 
over, the  constant  reinfection  of  the  surfaces  by  such  passages  prevents 
healthy  granulation  and  healing.  In  internal  blind  fistula  one  can  also 
explain  why  healing  does  not  take  place  on  account  of  the  imperfect 
drainage  and  the  constant  escape  of  faecal  material  into  it. 

These  theories,  however,  do  not  apply  to  blind  external  fistula,  in 
which  there  is  no  passage  of  fsecal  material  or  gases  into  the  cavity,  and 
hence  no  constant  irritation  or  apparent  recurrent  infection  of  the  walls. 
The  cause  has  been  ascribed  to  the  mobility  of  the  rectal  wall  which 
forms  a  portion  of  the  fistulous  tract;  the  constant  motion  of  a  part  will 
prevent  its  union  with  another,  and  there  is  constant  motion  of  the 
rectal  wall  due  to  respiratory  and  involuntary  peristaltic  action.  The 
irregularity  of  the  abscess  cavity,  the  existence  of  necrotic  tissues  in 
different  portions  of  the  tract — when  the  opening  is  not  sufficiently  large 
for  thorough  drainage,  and  when  these  tissues  have  not  been  removed  by 
curettage  or  dissection — may  prevent  the  closure  of  a  blind  external  fis- 
tula. These,  however,  do  not  explain  those  cases  in  which  wide  incision, 
thorough  drainage,  and  the  removal  of  sloughing  tissue  have  been  prac- 
tised, and  yet  they  do  not  heal,  notwithstanding  the  fact  that  the  most 
careful  and  persistent  search  has  failed  to  reveal  any  opening  into  the 
rectal  or  anal  canals.  In  such  cases  Hartmann  has  suggested  the  osmotic 
passage  of  gases  and  infecting  agents  from  the  rectum  through  the  thin 
rectal  walls  into  the  abscess  cavity  as  a  cause  of  persistent  infection 
and  consequent  delay  in  healing.  While  such  a  theory  is  ingenious  and 
possible,  it  is  utterly  without  proof. 

The  whole  secret  of  ehronicity  in  blind  external  fistula  lies  in  two 
facts:  first,  in  imperfect  drainage;  second,  in  persistent  reinfection, which 
may  come  through  an  opening  into  the  rectum  which  has  not  been  found, 
or  through  the  original  tract  of  infection,  the  lymphatic  channels.  Ee- 
ferring  to  the  chapter  upon  ischio-rectal  and  perirectal  abscesses,  it  will 
be  remembered  that  the  large  majority  of  these  was  ascribed  to  infection 
from  some  small  lesion  in  the  rectal  or  anal  canals,  the  septic  material 
being  taken  up  by  the  lymphatics  and  carried  into  the  surrounding  tis- 
sues. The  abscess  becomes  circumscribed  owing  to  a  thrombosis  of  the 
lymphatic  trunks.  This  thrombosis  stops  for  the  time  the  current  of 
septic  material  from  the  original  source,  but  as  soon  as  the  abscess  opens 
or  is  incised,  the  thrombosis  in  the  lymphatic  trunks  no  longer  obstructs 
the  circulation  in  the  distal  tracts.     Therefore  these  little  lymphatic 


358  THE  ANUS,  RECTUM,  AND   PELVIC   COLON 

vessels,  still  in  connection  with  the  rectal  surface,  continue  their  infec- 
tion of  the  abscess  cavity. 

Suppuration  extending  from  the  abscess  or  from  the  rectal  wound 
may  eventually  follow  along  these  tracts  and  enlarge  them  sufficiently 
for  the  admission  of  a  probe,  whereas  in  the  original  condition  they  are 
too  small  for  the  passage  of  either  the  pus  or  the  probe;  and  therefore 
while  there  actually  existed  a  communication,  it  was  too  small  for  dis- 
covery by  the  ordinary  means  of  research.  According  to  this  view  the 
etiological  factor  in  the  conversion  of  an  abscess  into  a  fistula  is  its  per- 
sistent connection  with  the  rectum  or  anal  canal  either  through  the 
lymphatic  tracts  or  through  a  distinct  opening. 

The  repair  of  abscess  cavities  depends  upon  the  proportionate  pro- 
duction of  round  cells  and  their  destruction  by  microbic  agents  (Quenu). 
If  the  production  exceeds  the  destruction,  repair  will  proceed,  and  rice 
versa.  If,  tlierefore,  a  wound  be  properly  cleansed  of  infectious  material 
and  constantly  kept  clean,  it  ought  in  a  general  way  to  heal  in  due  time. 
Of  course  one  must  take  into  consideration  the  constitutional  condition, 
the  rest  and  personal  attention  which  a  patient  can  give  to  his  treat- 
ment; but,  assuming  that  these  are  satisfactory,  the  healing  or  chro- 
nicity  of  such  abscess  cavities  will  depend  upon  the  extent  to  which  they 
are  protected  from  constant  reinfection.  The  fact  that  quite  a  number 
of  perirectal  abscesses  and  subsequent  fistulas  originate  in  injuries  and 
ulcerations  of  the  crypts  of  Morgagni,  from  which  lymphatic  absorption 
and  infection  take  place,  explains  why  the  rectum  is  so  often  searched  in 
vain  for  their  cause. 

These  ulcerations  may  continue  after  the  opening  and  drainage  of 
the  abscess,  and  unless  a  systematic  examination  of  all  these  pockets 
is  made  and  the  ulceration  cured,  suppuration  may  persist  on  account  of 
the  fact  that  the  cavity  receives  through  its  lymphatic  connection  with 
the  crypts  a  supply  of  pyogenic  germs  the  destructive  power  of  which 
overbalances  the  production  of  round  cells,  and  thus  prevents  healing. 
These  facts  emphasize  the  importance  of  searching  for  the  original 
source  of  infection,  and  for  any  minute  communication  with  the  rectal 
cavity. 

Sex. — Ano-rectal  fistula  is  undoubtedly  more  frequent  in  males  than 
in  females  (Bryant,  Guy's  Hosp.  Rept.,  London,  1861,  vol.  viii,  p.  87; 
GrefErath,  Deutsch  Zeitsch.  f.  Chir.,  vol.  xxxi,  p.  18;  Quenu  and  Hart- 
mann,  op.  cit.,  p.  180).  In  425  cases  collected  from  different  sources 
there  were  332  males,  89  females,  and  4  children  in  whom  the  sex  was 
not  mentioned. 

The  explanation  of  these  facts  lies  in  the  greater  exposure  of  men 
to  those  accidents  which  cause  perirectal  abscesses,  in  the  fact  that 
they  are  less  careful  in  their  personal  cleanliness,  and  in  the  habitual 


FISTULA  359 

overeating  and  drinking  in  the  male  sex — habits  which  predispose  to 
perirectal  inflammations  and  abscess. 

Age. — Fistula  may  occur  at  any  period  from  birth  to  very  old  age, 
but  it  is  essentially  a  disease  of  middle  life.  Quenu-and  Greffrath  state 
that  in  147  cases  only  4  occurred  under  the  age  of  eleven  years.  These 
figures  should  not  be  taken  as  conclusive  as  regards  the  disease  in  chil- 
dren. The  institutions  from  which  these  authors  obtained  their  statis- 
tics are  not  hospitals  for  children;  in  fact,  children  compose  a  very  small 
proportion  of  the  patients  in  either  institution,  and  therefore  the  facts 
do  not  properly  represent  the  proportion  of  fistulas  in  infants.  Deran- 
Borda  (These  de  Paris,  1882,  No.  233)  and  E.  Vigne  (These  de  Paris, 
1882,  No.  187)  have  gone  into  this  subject  somewhat  thoroughly,  and 
show  that  their  occurrence  in  children  is  considerably  more  frequent 
than  is  ordinarily  admitted  by  surgeons  to  general  hospitals.  At  the 
Polyclinic  Hospital  6  cases  of  fistula  were  treated  in  children  under  five 
years  of  age  during  the  past  five  years.  The  earliest  age  at  which  it 
has  been  seen  was  one  and  a  half  years. 

As  to  its  occurrence  in  old  people,  it  is  still  more  difiicult  to  obtain 
statistics.  In  the  Almshouse  Hospital  of  New  York  there  has  been  a 
large  number  of  old  people  affected  with  fistulas,  most  of  whom  had 
suffered  from  the  condition  for  many  years;  one  man,  aged  eighty-one, 
said  that  he  had  had  a  fistula  for  over  forty  years,  and  siiff ered  no  more 
from  it  at  the  time  of  examination  than  he  had  for  thirty  years  past. 
The  majority  of  fistulas  in  old  people  will  be  found  to  have  originated 
in  middle  life. 

Constitutional  Conditions. — Some  fistulas  are  said  to  arise  from  con- 
stitutional diseases  and  specific  inoculations;  thus  there  are  those  which 
follow  attacks  of  typhoid  fever,  variola,  measles,  dysentery,  and  scarlet 
fever;  also  those  which  arise  during  the  course  of  Bright's  disease,  cir- 
rhosis of  the  liver,  diabetes,  and  rheumatism.  If  dysentery  and  typhoid 
fever  are  excluded  it  is  a  question  if  any  of  these  diseases  have  any 
causative  influence  in  the  production  of  the  malady.  Ulceration  of  the 
rectum  may  occur  during  the  course  of  any  exhausting  disease,  but  it 
is  nearly  always  superficial,  and  the  fistulas  that  result  from  it  are 
almost  invariably  submucous  tracts  running  from  one  ulceration  to 
another.  Typical  fistula  in  ano  rarely  if  ever  results  from  such  con- 
ditions. In  typhoid  fever  and  dysentery  one  may  occasionally  find  a 
true  perirectal  abscess  due  to  the  infection  of  the  parts  by  the  specific 
bacilli  of  typhoid  or  dysentery  through  the  lymphatic  channels,  or  by 
the  escape  of  these  bacilli  into  the  tissues  through  ulcerative  perfora- 
tions of  the  rectal  wall;  but  even  this  type  of  fistula  is  exceedingly  rare. 

Tuberculosis. — The  influence  of  tuberculosis  in  the  production  of 
fistula  is  a  subject  which  has  been  discussed  so  widely  that  one  scarcely 


360  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

dares  to  venture  upon  it  without  devoting  an  amount  of  time  and  space 
altogether  out  of  proportion  to  a  book  of  this  character. 

The  etiological  influence  of  tuberculosis  in  the  production  of  fistula 
is  by  no  means  a  settled  question.  Every  surgeon  admits  that  a  certain 
number  are  tuberculous,  but  whether  it  is  an  initial  inoculation  with 
tubercle  bacilli  or  is  secondary  to  a  focus  elsewhere  in  the  body  is  still 
a  mooted  question.  Some  hold  that  there  is  no  such  condition  as  pri- 
mary tuberculosis  of  the  rectum,  it  being  impossible,  according  to  Koch, 
for  tubercle  bacilli  to  reach  the  rectum  through  the  intestinal  canal. 
On  the  other  hand  many  competent  observers  believe  that  fistula  is  fre- 
quently the  primary  manifestation  of  tuberculosis,  and  that  when  the 
disease  limits  itself  to  this  area  it  may  remain  localized  for  long  periods 
of  time.  In  order  to  come  to  some  conclusion  in  regard  to  the  relation- 
ship between  tuberculosis  and  fistula  it  is  necessary  to  look  at  the  sub- 
ject from  two  points  of  view:  first,  tuberculosis  in  the  fistulous,  and,  sec- 
ond, fistula  in  the  tuberculous.  Some  elaborate  statistics  have  been 
compiled  to  determine  this  relationship,  and  yet  none  are  particularly 
satisfactory.  Allingham  states  that  14  per  cent  of  all  fistulous  cases 
seen  by  him  were  tuberculous.  Hartmann,  in  a  study  of  over  600  cases 
of  fistula,  states  that  30  per  cent  were  tuberculous;  Greffrath,  16  per 
cent;  and  Meyer  in  a  private  communication  states  that  in  ]\It.  Sinai 
Hospital  of  New  York,  d^-Q  per  cent  of  all  the  cases  of  fistula  were  tuber- 
culous. In  the  author's  experience  nearly  50  per  cent  of  the  fistulas 
that  have  come  under  his  observation  in  the  Polyclinic,  Almshouse, 
and  Workhouse  Hospitals  have  either  suffered  from  tuberculosis  at  the 
time  or  afterward. 

There  is  a  much  closer  agreement  among  observers  as  to  the  percent- 
age of  fistulas  in  the  tuberculous,  as  the  following  table  exhibits: 

Taylor  (London  Lancet,  1890) 1  per  cent. 

Hartmann  (op.  cit.,  p.  4) 4.91  " 

Brompton  Hospital  Reports 4  " 

Douglas  Powell  (Quenu  and  Hartmann,  p.  ISl)  ....   5  " 

St.  Joseph's  Home,  Caldwell  (3,000  cases) 0.9 

Mt.  Sinai  Hospital  (3,749  cases),  Meyer 1.3  " 

Almshouse  Hospital,  New  York,  tuberculous  wards.   2.1  " 

In  these  statistics  one  observes  two  classes:  institutions  in  which 
there  are  surgical  wards,  and  others  in  wliich  there  are  none.  It  is 
very  clear  in  the  case  of  the  Mt.  Sinai  Hospital  that  all  the  fistulous  cases 
were  sent  to  the  surgical  side  and  never  reached  the  medical  side, 
whereas  all  the  cases  of  general  tuberculosis  were  sent  to  the  medical 
wards;  therefore,  the  proportion  among  the  tuberculous  is  very  small. 
On  the  other  hand  Hartmann,  Powell,  and  the  Brompton  Hospital  re- 
ports deal  with  a  general  hospital  clientele.     Such  institutions  take  in 


FISTULA  361 

very  few  pulmonary  consumptives,  whereas  they  admit  all  cases  of 
fistula  whether  they  are  tuberculous  or  not;  therefore  their  percentages 
are  unusually  high  compared  to  those  of  St.  Joseph's  Home,  Meyer's 
general  statistics,  and  those  of  the  Almshouse  tuberculous  wards.  On 
the  whole  the  true  percentage  is  probably  somewhere  between  the  5 
per  cent  of  Powell  and  the  y\  of  1  per  cent  in  St.  Joseph's  Home. 
With  such  facts  in  view  the  influence  of  tuberculosis  in  the  produc- 
tion of  fistula  is  undeniable.  The  fact  that  fistula  in  the  tuberculous 
is  so  much  less  frequent  proportionately  than  tubercle  in  the  fistulous, 
renders  it  almost  impossible  to  doubt  the  occurrence  of  primary  tuber- 
culosis in  these  parts.  Modern  observers  have  come  to  hold  to  the  view 
that  abscesses,  ulceration,  and  fistula  of  the  rectum  may  be  caused 
by  direct  inoculation  of  injuries  and  abrasions  by  the  tubercle  bacilli 
ingested  with  the  food  and  carried  through  the  intestinal  tract,  not- 
withstanding the  observations  of  Koch.  If  such  facts  can  be  estab- 
lished, if  it  is  jDOsitively  known  that  the  anal  manifestation  is  the  only 
focus  of  tuberculosis  in  the  system,  and  if,  as  will  be  shown  farther  on, 
this  focus  is  absolutely  walled  ofi;  from  any  connection  with  the  general 
system,  it  will  have  a  bearing  of  the  greatest  importance  upon  the  man- 
agement of  such  cases. 

Syphilis.- — Of  the  influence  of  syphilis  in  the  production  of  fistula 
little  positive  information  is  obtainable.  ISTearly  all  the  cases  of  fistula 
attributed  to  syphilis  have  been  those  secondary  to  stricture  of  the  rec- 
tum. In  such  the  fistula  is  usually  a  complicated  or  complex  one  due 
to  perforation  of  the  rectal  wall  by  ulcerative  processes,  and  the  infec- 
tion of  the  perirectal  tissues  subsequent  to  this.  The  fistula  therefore 
becomes  one  of  simple  infection,  and  not  of  a  specific  nature  itself.  This 
might  be  said  more  jDositively  if  we  knew  the  specific  organism  of 
syphilis  and  could  eliminate  it  by  microscopic  or  culture  examinations, 
but  unfortunately  there  are  no  means  at  present  by  which  the  presence 
of  such  a  germ  can  be  proved  or  disproved. 

A  number  of  such  fistulas  entirely  heal,  whereas  the  stricture  and 
specific  disease  continue.  This  fact  would  indicate  that  the  fistula 
was  a  complication  and  not  a  part  of  the  disease.  On  the  other  hand 
there  are  fistulas  supposed  to  be  simple,  inflammatory  conditions,  which 
absolutely  refuse  to  heal  until  the  patients  are  put  upon  antisyphilitic 
medication,  when  they  at  once  assume  a  healthy  granulation,  and  heal 
promptly  and  thoroughly.  It  is  therefore  an  unsettled  question  as  to 
how  much  influence  syphilis  has  in  the  production  of  fistula;  but  with 
regard  to  its  delaying  healing  after  operations  for  fistula,  there  is  no 
room  for  doubt. 

Symptoms. — It  may  be  assumed  that  the  symptoms  of  abscess  have 
preceded  those  of  fistula  at  some  time  more  or  less  remote;  that  the 


362  THE  ANUS,  RECTUM,  AND   PEL\aC  COLON 

abscess  has  opened  either  internally,  externally,  or  in  both  directions; 
that  the  acute  phenomena  have  disappeared,  and  that  the  condition  has 
assumed  a  chronic  state.  From  this  time  the  s}Tnptoms  may  be  said  to 
belong  to  fistula,  and  they  will  be  reviewed  as  seen  in  the  various  types 
of  the  disease. 

Blind  External  Fistula. — In  this  form  of  fistula,  after  the  inflam- 
matory s}Tnptoms  have  subsided,  the  abscess  instead  of  healing  assumes 
an  inoffensive,  painless  condition.  The  discharge  decreases  and  be- 
comes more  serous;  the  tissues  become  somewhat  thickened  and  brawny 
about  the  aperture;  there  is  some  itching  or  irritation,  sometimes  a 
slight  dragging  of  the  parts  upon  certain  motions,  and  discomfort  from 
sitting  in  certain  positions;  there  is  rarely,  if  ever,  any  absolute  pain; 
the  discharge  may  require  the  wearing  of  a  napkin  or  some  small  dress- 
ing, or  it  may  be  so  limited  that  it  scarcely  stains  the  linen;  it  may 
cease  for  certain  periods  owing  to  the  temporary  closure  of  the  open- 
ing; while  this  continues  there  will  be  a  feeling  of  fulness  and  discom- 
fort in  the  parts,  but  these  rapidly  disappear  upon  the  reopening  of  the 
aperture.  This  opening  and  closing  may  go  on  for  indefinite  periods, 
and  sometimes  the  closure  may  be  so  firm  that  the  abscess  will  burrow 
and  open  at  another  portion  of  the  surface,  this  opening  being  followed 
by  the  same  relief  as  in  the  first  case. 

The  symptoms  during  the  period  of  closure  are  not  those  of  an 
acute  abscess  accompanied  with  chill,  fever,  and  great  distress,  but  they 
resemble  those  of  the  cold  abscess.  During  one  of  these  closures  the 
secondar}'  opening  may  take  place  within  the  rectum  and  thus  form 
what  would  appear  as  a  blind  internal  fistula;  but  this  condition  lasts 
only  a  short  time,  as  the  original  opening  or  another  upon  the  surface 
is  sure  to  give  vent  to  the  collected  pus,  thus  producing  a  complete 
fistula. 

Palpation  will  reveal  a  thick  and  brawny  condition  of  the  skin  over 
the  fistulous  tract,  and  generally  an  induration  of  greater  or  less  ex- 
tent beneath  it.  Deep  pressure  around  the  opening  will  give  some  pain, 
and  usually  results  in  forcing  a  drop  of  sero-pus  from  the  aperture. 

There  is  ordinaril}'  no  pain  on  defecation,  and  no  spasm  of  the 
sphincters.  In  simple  fistulas,  and  even  in  many  cases  of  the  localized 
tubercular  type,  the  patients  remain  in  the  best  of  health  and  fre- 
quently increase  in  weight.  The  rectum  presents  no  abnormalities  to 
the  touch  or  sight  except  that  one  can  sometimes  feel  the  induration 
of  the  fistulous  tract  through  its  walls. 

Blind  Internal  Fistula. — The  s}Tiiptoms  of  this  variety  are  much 
more  obscure.  The  patient  will  give  the  history  of  rectal  ulceration  or 
of  having  had  chilliness  and  temperature  with  pain  and  fulness  in  the 
rectum,  followed  by  a  discharge  of  blood  or  pus  which  gave  partial 


FISTULA  363 

relief.  The  discharge,  however,  continues,  and  pain  on  defecation  is 
present  with  more  or  less  tenesmus  or  spasm  of  the  sphincter.  If  the 
condition  has  existed  for  any  length  of  time,  hypertrophy  of  this  muscle 
may  be  present.  All  of  these  symptoms  subside  and  recur  from  time 
to  time.  The  subsidence  is  associated  with  an  increase  of  the  discharge, 
and  the  recurrence  with  a  decrease.  Owing  to  the  fact  that  these  fistulas 
are  usually  submucous  or  submuco-cutaneous,  palpation  around  the 
anus  does  not  ordinarily  give  to  the  examiner  a  sense  of  tension,  swell- 
ing, or  induration;  nor  does  it  produce  that  acute  pain  which  follows 
in  abscess  or  blind  external  fistula. 

With  the  finger  in  the  rectum  one  may  feel  sometimes  a  small  indu- 
rated tract  running  upward  from  the  base  of  the  fistula  to  the  opening 
in  the  rectum,  or  if  the  cavity  be  only  partially  emptied  of  its  con- 
tents, a  boggy,  compressible  mass  may  be  observed.  Ordinarily  the 
opening  can  be  felt  and  located.  Where  this  can  not  be  done,  the  use 
of  instruments  will  be  necessary  for  the  diagnosis.  For  this  purpose 
the  conical,  fenestrated  speculum  is  by  all  means  the  most  satisfactory. 
By  it  one  can  bring  the  aperture  into  view,  and  while  he  presses  with 
his  finger  upon  the  loAver  part  of  the  tract  he  will  be  able  to  see  a  drop 
of  pus  exude  from  the  opening.  Having  determined  such  an  opening, 
one  can  introduce  a  bent  probe  into  it  through  the  speculum,  and  by  the 
introduction  of  one  probe  after  the  other,  each  being  bent  a  little  more 
upon  itself,  he  can  determine  absolutely  the  depth  and  direction  of  the 
tract. 

Sometimes  the  small  laryngeal  mirror  may  be  useful  to  determine 
the  opening,  especially  in  those  cases  in  which  it  is  situated  in  the 
posterior  rectal  cul-de-sac,  or  when  it  leads  downward  from  a  valve-like 
opening  either  in  the  rectal  wall  or  in  one  of  the  crypts  of  Morgagni. 

The  introduction  of  the  probe  in  these  cases  usually  causes  an  acute 
pain  when  it  approaches  the  anal  region,  and  it  may  be  followed  by  a 
drop  of  blood. 

Complete  Fistula. — Complete  fistula  is  generally  more  easily  diag- 
nosed than  either  of  the  other  varieties.  Aside  from  the  history  of 
abscess  there  is  more  irritation,  greater  spasm  of  the  sphincter,  more 
or  less  pain  on  defecation,  involuntary  escape  of  gas  and  fsces,  difficulty 
in  maintaining  cleanliness,  and  a  constant  disagreeable  odor  to  the- 
parts,  all  of  which  have  a  depressing  influence  upon  a  sensitive  indi- 
vidual, leading  sometimes  to  attacks  X)f  hypochondria  and  even  melan- 
cholia. 

The  discharge  is  greater  than  in  blind  external  fistula,  owing  to 
the  fact  that  the  infection  is  more  continuously  renewed. 

Pain  is  not  a  prominent  symptom,  but  it  is  always  present  to  some 
extent.    The  external  opening  is  often  tender  to  the  touch;  it  may  be 


364  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

elevated  like  a  nipple  or  depressed  by  cicatricial  contraction.  The  in- 
flammatory symptoms  of  abscess  may  sometimes  recur  owing  to  the 
obstruction  in  the  fistulous  tract  by  necrotic  tissues  or  the  escape  of 
faecal  substances  from  the  rectum.  The  fistula  may  also  be  kept  tender 
by  the  passage  of  irritating  diarrhceal  stools  which  cause  further  infec- 
tion, and  may  bring  about  the  formation  of  other  abscesses  which  open 
into  the  first  tract,  or  at  other  points  upon  the  skin,  thus  producing 
complex  fistula. 

The  sphincters  in  this  type  of  fistula  are  nearly  always  spasmodic 
and  hypertrophied.  An  examination  by  palpation  around  the  rectum 
will  nearly  always  elicit  an  indurated  tract  leading  upward  and  toward 
the  anus.  With  the  index  finger  of  one  hand  in  the  rectum  and  that 
of  the  other  outside,  one  may  generally  trace  this  indurated  tract  to 
the  internal  opening  in  the  rectum.  This  opening  can  almost  always 
be  felt  and  absolutely  determined  by  touch. 

Diagnosis. — Ordinarily  when  the  patient  presents  himself  for  the 
treatment  of  fistula,  the  diagnosis  has  been  already  made  by  himself  or 
his  friends.  To  laymen  every  opening  about  the  anus  which  discharges 
pus  is  a  fistula,  whether  it  be  acute  or  chronic.  The  surgeon,  however, 
must  be  more  explicit;  he  should  not  only  determine  the  existence  of 
a  fistula,  but  its  character,  its  origin  and  its  pathological  nature.  In 
all  cases  of  fistula  the  history  of  injury,  discomfort,  pain,  and  fulness 
about  the  rectum,  with  or  without  constitutional  symptoms,  can  be 
elicited  by  careful  interrogation.  The  length  of  time  existing  between 
such  symptoms  and  tlie  examination  will  determine  in  a  certain  number 
of  cases  whether  the  sinus  shall  be  termed  an  abscess  or  a  fistula.  All 
blind  fistulas  are  practically  chronic  abscesses;  when  they  have  existed 
for  several  weeks  after  having  been  opened  and  drained,  and  show  no 
tendency  toward  healing,  they  may  be  termed  fistulas,  but  the  fact  that 
an  abscess  has  existed  for  weeks  with  insufficient  drainage  does  not 
justify  the  assumption  that  the  condition  is  one  of  fistula.  ]\Iany  such 
will  heal  at  once  upon  proper  drainage  and  treatment  being  estab- 
lished. Chronicity,  therefore,  under  favorable  circumstances  for  heal- 
ing, is  the  pathognomonic  symptom  of  fistula. 

To  examine  for  fistula  the  patient  should  be  laid  upon  his  left  side 
with  the  hips  elevated,  in  the  exaggerated  Sims's  posture,  and  close 
attention  should  be  paid  to  each  opening  and  the  intervening  tract. 

The  External  Opening. — Careful  observation  should  be  made  of  all 
the  external  parts.  The  external  opening  will  appear  as  an  ulceration,  a 
pouting  tubercle  (Fig.  120),  or  a  small  cicatricial  depression  near  to  or  re- 
mote from  the  anus;  sometimes  in  submucous  fistula  it  appears  as  a  fissure 
between  the  radial  folds  of  the  anus,  and  can  only  be  seen  by  separating 
the  buttocks  forcibly;  occasionally  it  will  be  found  closed  at  the  time 


FISTULA 


365 


of  the  examination,  but  when  such  is  the  case  a  small  rose-colored  or 
whitish  spot  covered  with  a  thin  cicatrix  or  mucous-like  tissue  will  dis- 
close its  site.  This  tissue  is  very  fragile,  and  can  be  broken  by  stretch- 
ing the  edges  apart,  or  punctured  with  the  end  of  a  probe.  After  punc- 
ture a  small  drop  of  pus  will  generally  exude.  In  tuberculous  subteg- 
umentary  fistulas  the  opening  may  be  at  the  margin  or  in  the  midst 
of  an  extensive,  ragged  ulceration  (Fig.  89). 

The  Tract. — Around  the  margin  of  the  external  aperture,  if  grasped 
between  two  fingers,  there  will  be  felt  a  dense  fibrous  deposit.  By  care- 
ful palpation  one  may  follow  this  induration  throughout  its  extent.    If 


Fig.  120. — External  Opening  of  Subtegumentaey  Fistula. 

it  goes  deep  into  the  perirectal  tissues  the  finger  introduced  into  the 
rectum  will  trace  it  inward  and  around  the  anus  until  its  internal  open- 
ing is  reached;  sometimes  it  is  necessary  to  use  the  fingers  of  both  hands, 
one  being  placed  in  the  rectum  and  pressing  downward,  the  other  pal- 
pating the  tissues  around  the  anus.  By  this  means  the  indurated  tract 
and  its  direction  can  generally  be  clearly  determined,  and  wherever 
there  is  an  internal  opening  this  induration  will  always  lead  directly 
or  by  some  circuitous  route  to  it.  The  tract  is  not  always  tubular  and 
direct,  for  large  cavities  may  interrupt  its  course,  and  it  may  be  very  tor- 
tuous, almost  surrounding  the  anus,  but  the  expert  finger  can  almost 
always  detect  the  entrance  into  the  rectum. 

The  Internal  Opening. — This  opening  may  be  wide  and  gaping,  due 
to  ulcerative  destruction;  it  may  assume  the  form  of  a  small  papilla, 
or  it  may  be  in  the  shape  of  a  depressed  cicatricial  opening  just  large 


366  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

enoi;gh  to  admit  the  end  of  a  fine  probe.  It  may  also  occupy  the  base 
of  one  of  the  crypts.  It  ought  always  to  be  located  by  digital  touch. 
When  it  has  once  been  felt  in  connection  with  an  external  opening 
there  is  no  longer  any  question  as  to  the  existence  of  complete  fistula. 
To  the  educated  finger  irregularities  in  the  mucous  membrane,  such  as 
ulceration,  elevated  papillae,  or  depressed  cicatricial  openings,  are  easy 
of  recognition.  When  this  touch  is  combined  with  the  existence  of  a 
fibrous  mass  leading  from  the  external  opening  to  the  point  at  which  the 
internal  irregularity  is  felt,  the  diagnosis  is  confirmed  beyond  a  doubt. 

The  probe,  therefore,  is  not  necessary  in  the  diagnosis  of  blind  ex- 
ternal or  complete  fistulas.  Its  use  consists  in  determining  the  depth 
and  direction  of  the  pockets  and  sinuses.  In  certain  cases  (Fig.  118)  it 
would  be  impossible  to  introduce  the  probe  into  the  internal  from  the 
external  opening  on  account  of  the  tortuosity  of  the  tracts;  it  is  only 
by  incising  them  step  by  step  that  one  is  able  to  make  the  probe  enter 
the  internal  aperture  at  all.  If  one  depended  upon  this  instrument  for 
diagnosis  of  complete  fistula  he  would  frequently  determine  them  to  be 
of  the  blind  external  variety,  and  operation  on  this  basis  would  most 
surely  fail.  The  probe  is  very  useful,  however,  in  the  examination  of 
fistulas  with  openings  remote  from  the  anal  circumference.  In  these 
cases  the  tract  is  sometimes  so  deep  and  covered  by  such  dense  tissues 
that  it  is  impossible  to  make  out  its  course  by  palpation,  and  while  one 
may  satisfy  himself  by  digital  examination  of  the  existence  of  an  in- 
ternal opening,  the  direction  and  extent  can  only  be  determined  by 
the  use  of  this  instrument.  It  is  also  necessary  in  those  cases  in  which 
the  opening  is  through  one  of  the  crypts,  for  here  the  valve  covers  it 
up  and  interferes  with  the  touch.  The  surgeon  should  therefore  have  a 
variety  of  these,  some  very  fine,  others  of  medium  size,  and  still  others 
large  and  long;  they  should  all  be  supplied  with  flat  handles  so  that  one 
can  always  tell  in  what  direction  the  point  is  extending  when  it  is 
introduced  bent  upon  itself. 

Another  method  of  diagnosis  of  complete  fistulas  is  that  of  injecting 
colored  liquids  through  the  external  opening.  A  syringe  filled  with 
methylene  blue,  milk,  or  some  other  colored  fluid  is  introduced  into 
the  external  opening,  and  the  liquid  is  forcibly  injected  into  the  tract. 
If  an  internal  opening  exists  it  is  supposed  that  the  fluid  will  come  out 
through  the  rectum.  Such  will  be  the  case  provided  the  internal  open- 
ing is  not  valve-like,  in  which  case  the  flap  may  be  pressed  up  against 
the  side  of  the  rectal  wall,  thus  completely  closing  it,  and  only  a  false 
inference  can  be  drawn  from  the  procedure.  If  too  much  force  be  used 
the  fluid  may  break  through  into  the  cellular  tissues  around  the  rectum 
and  thvis  do  harm.  The  use  of  the  conical  speculum  to  determine  the 
internal  opening  has  been  already  described. 


FISTULA  367 

We  have  laid  great  stress  upon  finding  the  internal  opening,  because 
we  believe  that  it  is  the  most  important  step  in  the  treatment  of  fistula.  It 
is  the  gateway  for  constant  reinfection,  and  unless  it  is  obliterated  we  can 
not  expect  the  parts  to  heal,  however  wide  or  deep  our  incisions  may  be. 

The  diagnosis  of  blind  internal  fistula  will  depend  largely  upon  the 
symptoms  present  in  the  case.  These  have  been  detailed  above,  but 
it  may  be  worth  while  to  reiterate  one  particular  feature,  the  remission 
and  recurrence  of  the  discomfort  and  discharge  which  are  always  asso- 
ciated with  this  type.  With  the  conical  speculum  one  is  usually  able 
to  see  the  opening,  or  at  least  determine  the  site  from  which  the  pus 
discharges  when  pressure  is  made  around  the  anus.  Occasionally,  how- 
ever, there  are  symptoms  of  blind  internal  fistula  where  the  opening 
can  not  be  determined.  In  such  cases  there  may  exist  what  is  termed 
a  complete  intrarectal  fistula,  which  consists  in  two  mucous  openings 
connected  by  a  fistulous  tract  completely  within  the  anus  or  rectum; 
such  a  condition  is  rarely  seen  in  the  rectum  itself  except  in  cases  of 
multiple,  tubercular  ulceration,  where  two  ulcers  are  connected  by  a  sub- 
mucous tract.  Within  the  anus,  however,  it  is  not  such  a  rare  condition, 
and  has  been  termed  "  bimucous  anal  fistula  ";  the  term  complete  intra- 
anal  fistula  would  more  accurately  describe  it. 

Complex  Fistulas. — In  complex  fistula,  while  it  may  be  very  easy  to 
find  the  internal  opening,  it  is  not  always  such  a  simple  proposition  to 
determine  which  one  of  the  numerous  external  openings  is  most  directly 
connected  with  it.  All  of  them  are  connected  with  one  general  abscess 
cavity  by  more  or  less  tortuous  tracts,  and  this  in  turn  is  connected  with 
the  internal  opening  by  another  narrow  channel.  It  is  very  easy  to  in- 
troduce a  probe  into  this  cavity  from  either  the  rectal  or  cutaneous 
aperture,  but  sometimes  impossible  to  pass  it  from  one  opening  to  the 
other.  The  chief  thing  to  be  learned  is  the  course  of  the  tract  that 
leads  from  the  rectum  into  the  abscess  cavity;  if  this  is  obliterated  and 
the  constant  reinfection  through  it  stopped,  the  other  tracts  can  be 
easily  managed.  The  simplest  way  to  determine  this  is  to  open  the 
cavity  freely  so  that  the  finger  can  be  introduced,  and  then  pass  a 
probe  from  the  rectal  opening  down  upon  it.  All  this  should  be  done 
at  the  time  of  operation,  as  it  requires  general  anaesthesia.  With  several 
external  openings  in  sight  and  the  internal  one  located  by  touch,  the 
diagnosis  of  complex  fistula  is  complete.  Flexible  bougies,  the  injec- 
tion of  colored  fluids,  and  various  probes  are  unnecessary  to  diagnose 
this  condition.     The  finger  does  it  all. 

Anatomical  Character. — The  surgeon  should  always  determine  the 
anatomical  character  of  a  fistula  before  operating  or  giving  an  opinion. 
The  prognosis  is  very  different  in  the  subtegumentary  and  subaponeu- 
rotic types.    The  distinction,  however,  is  quite  simple. 


368 


THE  ANUS,  RECTUM,   AND   PELVIC  COLON 


In  the  subtegumentary  variety  there  is  usually  a  history  of  very 
slight  constitutional  disturbances,  perhaps  a  thrombotic  hemorrhoid  or 
a  furuncle;  the  tract  is  generally  straight,  although  they  sometimes  run 
circularly  around  the  anus  (Fig.  121);  the  induration  is  not  marked;  the 
external  opening  is  patulous  and  rarely  more  than  f  to  1  inch  from  the 
anus,  the  internal  is  rarely  above  Hilton's  line;  the  overlying  tissues  are 
healthy  and  the  discharge  is  usually  very  scanty.  The  induration  of  the 
tract  or  a  probe  passed  through  it  can  easily  be  felt  by  the  finger  through- 
out its  course. 

In  the  submuscular  or  subaponeurotic  variety  there  is  usually  a 
history  of  injury  or  abscess  with  constitutional  dist\irbances;  the  tracts 

run  in  all  directions, 
and  may  extend  entire- 
ly around  the  rectum; 
the  external  opening 
is  a  cicatricial  depres- 
sion or  pouting  tuber- 
cle, generally  more 
than  an  inch  from  the 
anus,  and  bears  no  con- 
stant relationship  to 
the  internal:  the  latter 
is  usually  between  the 
two  sphincters,  but 
may  be  much  higher; 
the  induration  of  the 
tract  and  infiltration  of 
the  surrounding  tissues 
are  very  marked;  it  is 
often  difficult  to  pass  a 
probe  from  one  open- 
ing to  the  other;  the 
muscular  or  aponeu- 
rotic fibers  may  be  felt  between  an  instrument  introduced  into  the  fistula 
and  the  finger  in  the  rectum;  the  discharge  is  often  profuse,  and  may  be 
accompanied  by  gas  and  faecal  material.  Occasionally  these  fistulas  pass 
directly  through  the  muscles  (Fig.  122);  in  such  cases  there  is  great 
hypertrophy  of  the  sphincter  and  marked  constipation. 

Origin. — It  is  a  matter  of  importance  for  the  surgeon  to  determine 
not  only  the  existence  of  a  fistula  and  its  anatomical  character,  but  also 
if  possible  its  origin.  ^Many  fistulas  originate  in  other  organs  than  the 
rectum. 

A  case  reported  by  the  writer  (N.  Y.  Med.  J.,  July  1,  1893)  showed 


Flo.    121. SuBTEGl'MEXTAIiY     FiSTULA    ALMOST    Sl'KKOl:NI)ING 

THE  Anus. 


FIST  ex  A 


369 


the  fallacy  of  concluding  that  a  fistulous  tract  is  connected  with  the 
rectum  simply  because  it  closely  approaches  this  organ.  In  this  in- 
stance (Fig.  123)  the  fis- 
tula almost  entirely  sur- 
rounded the  rectum,  and 
opened  externally  upon 
the  right  side  at  a  distance 
of  about  2  inches  from  the 
anus.  After  laying  it  open 
and  follo\\'ing  it  first 
around  the  right  side  to 
the  anterior  commissure, 
and  then  around  the  pos- 
terior conmiissure  and  on 
the  left  side  forward  in 
the  perinaBum  to  the  junc- 
ture of  the  scrotum,  it  was 
discovered  that  what  was 
apparently  an  ano-rectal 
was  really  a  urethral  fis- 
tula which  had  no  connec- 
tion whatever  with  the 
rectum.  An  ano-rectal  fistula  the  tract  of  which  is  very  similar  to  this 
is  illustrated  in  Fig.  124. 

Fistulas  may  also  originate  in  a  suppurating  ovary  or  broad  ligament 

and  open  very  close  to 
the  margin  of  the 
anus.  These  have  no 
connection  with  the 
intestinal  canal. 

jSTecrosis  of  the 
bones  of  the  pelvis, 
psoas  abscess,  and  tu- 
bercular diseases  of 
the  vertebras  may  all 
result  in  fistulous 
openings  around  the 
anus  and  simulate 
blind  external  fistula. 
In  one  interesting 
case  which  the  writer 


Fig.  122. — Straight  Tubular  Fistula  passing  dieect- 
ly  theough  exteexal  sphinctee. 
Drawn  from  po!<t-mortem  dissection. 


Fig.  123.— Teact  of   Ueixaet    Fistula  -which    sihtlated 
THE  Aij^o-eectal  Yaeiett. 


saw  some  years  ago,  a  fistulous  tract  ran  up  posterior  to  the  rectum, 
and  the  probe  impinged  upon  the  mucous  membrane  at  a  height  of 
34 


370 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


about  2|  inches;  on  widening  the  tract,  however,  it  was  found  that 
the  condition  was  due  to  a  dermoid  C3'st  which  had  ruptured  in  the  retro- 
rectal space,  causing  an  abscess  in  this  location.  The  remains  of  the 
cyst  were  removed,  and  what  had  been  supposed  to  be  a  chronic  fistula 
rapidly  healed. 

Where  the  fistula  originates  in  perforation  or  stricture  of  the  rectum, 
one  should  be  able  to  determine  these  facts  by  digital  and  instrumental 
examination.  When  it  is  due  to  infection  through  the  lymphatic  chan- 
nels, the  abrasion  or  ulceration  through  which  the  infection  first  oc- 
curred may  heal  and  leave  so  slight  an  evidence  of  its  existence  that  it 
will  be  impossible  to  determine  the  origin.  The  patient's  previous  his- 
tory as  to  diseases  of  the  urethra,  bladder,  or  generative  organs  should 
be  investigated.     "Wherever  a  urethral   stricture   has  existed,   a   deep 

urethritis,  or  evidence 
of  pelvic  inflanunation 
in  women,  one  may 
suspect  the  origin  of  a 
fistulous  tract  to  be 
other  than  intrarectal. 
In  a  case  of  peri- 
rectal abscess  due  to 
perforation  of  the 
deep  urethra  with  a 
small  filiform  bougie, 
there  was  never  any 
urinary  extravasation, 
and  yet  within  a  few 
liours  after  the  intro- 
duction of  the  instrument  a  chill  and  fever  followed,  and  a  large  abscess 
developed,  the  symptoms  being  chiefly  referred  to  the  rectum.  A  deep 
perineal  incision  was  made,  and  a  quantity  of  pus  let  out  from  an  abscess 
which  seemed  ready  to  burst  into  the  rectum.  The  fistula  that  resulted 
from  this  abscess  continued  for  some  time,  but  was  finally  cured  by 
drainage  and  thorough  dilatation  of  the  strictured  urethra. 

Fistulas  which  result  from  carcinoma  and  syphilitic  stricture  of  the 
rectum  usually  occur  in  such  late  stages  of  the  disease  that  they  are  a 
matter  of  small  importance  compared  with  the  original  disease.  If  the 
diagnosis  of  cancer  has  not  been  made  and  proper  treatment  insti- 
tuted before  the  occurrence  of  the  fistula,  one  may  practically  say 
that  it  is  useless  at  this  time  to  attempt  any  radical  interference. 
The  origin  of  the  fistula,  therefore,  will  always  have  an  important 
bearing  upon  its  treatment,  and  search  for  the  same  should  never  be 
neglected. 


Fig.  124. — Outline  of  Tortuous  Ano-rectal  Fistula. 


FISTULA  371 

Pathological  Xatuee  ot  Fistula. — Having  determiued  tlie  pres- 
ence, anatomical  character,  and  origin  of  a  fistula,  its  pathological  nature 
should  be  learned,  as  it  is  impossible  to  decide  upon  the  treatment  or 
give  a  correct  prognosis  until  thi5  has  been  done.  In  those  cases  due 
to  carcinoma  or  fibrous  stricture,  only  radical  operations  can  promise 
any  permanent  relief.  On  the  other  hand,  those  due  to  simple  infection 
and  inflammatory  processes  may  all  be  cured  by  minor  procedures.  The 
rectum  should  be  thoroughly  seaxched  for  evidences  of  malignant  or 
specific  disease;  and  the  history  should  be  investigated  ^vith  regard  to 
typhoid  fever,  dysentery,  and  pneumonia,  as  abscess  and  fistula  may  fol- 
low all  of  these  conditions.  The  important  pathological  factors,  how- 
ever, are  tuberculosis,  syphilis,  and  cancer. 

Tubercular  Fistula. — To  distinguish  tubercular  from  non-tubercular 
fistulas  is  said  to  be  very  easy,  but  it  requires  exact  and  scientific  ex- 
amination, ^hile  there  are  certain  general  characteristics  of  tubercular 
fistula,  one  may  be  easUy  misled,  when  it  is  the  primary  manifestation 
of  tuberculosis,  by  the  absence  of  constitutional  and  general  symptoms. 

The  external  opening  in  this  variety  may  be  large  or  small.  TThere 
it  origiuates  in  a  perianal  tubercular  ulcer,  it  will  appear  as  an  irregular, 
wide  aperture  with  red  undermined  edges,  and  a  base  of  pale,  proliferat- 
ing granulations.  TTliere  it  originates  in  infection  carried  along  the 
lymphatic  channels  that  results  in  an  abscess  which  opens  upon  the 
skin,  the  external  aperture  may  be  surmounted  by  a  small,  elevated,  nip- 
ple-like tubercle  with  an  opening  in  its  center.  Always  in  such  cases, 
however,  the  skin  about  the  tubercle  will  be  undermined. 

Some  stress  has  been  laid  upon  the  long  silky  condition  of  the  hair 
around  the  anus,  the  club-shaped  finger-nails,  and  the  general  physiog- 
nomy of  the  patient,  his  voice,  complexion,  etc.  All  these  symptoms 
belong  to  constitutional  tuberculosis,  but  they  do  not  prove  the  fact 
that  the  fistula  itself  is  tubercular.  One  may  occasionally  see  a  suuple 
fistula  in  a  tuberculous  individual.  Loss  of  fiesh  may  be  produced  by 
any  irritating  disease  of  the  rectum,  whether  it  is  fistula,  ulceration,  or 
fissure;  all  catarrhal  diseases  of  the  rectum  and  sigmoid  and  all  in- 
flammatory conditions  of  the  lower  end  of  the  intestinal  canal  interfere 
with  the  digestion,  appetite,  and  reparative  processes,  and  may  result 
in  loss  of  flesh,  so  it  is  not  a  conclusive  spnptom  of  the  tubercular  nature 
of  a  fistula. 

The  discharge  from  a  tuberculous  fistula  is  generally  small  in  C[uan- 
tity,  thin,  and  milky  white;  it  is  rarely  a  thick,  creamy  pus.  The  indu- 
ration about  the  tract  of  tuberculous  fistula  is  greater,  as  a  rule,  than 
that  about  the  simple  varieties. 

Pain  and  sensitiveness  to  touch  are  markedly  absent  in  tubercular 
fistula,  but  this  is  not  invariably  so.     Xight-sweats,  interrupted  sleep. 


372  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

and  evening  elevation  of  temperature  may  be  seen  in  these  cases;  but 
when  they  are  present,  genito-urinary  or  pulmonary  tuberculosis  is  gen- 
erally found  to  exist.  "\Miile  all  these  symptoms  may  lend  probability 
to  the  tubercular  nature  of  a  fistula,  there  is  but  one  absolutely  certain 
method  to  diagnose  it,  and  that  is  by  microscopic  examination  and 
culture  tests.  Examination  of  the  discharges  for  the  bacilli  is  often 
misleading;  very  frequently  one  fails  to  find  them  in  the  pus,  whereas 
they  may  be  abundant  in  scrapings  of  the  granular  tissue  from  the 
fistulous  tract,  or  in  the  perifistulous  tissue  after  it  has  been  dissected 
out.  Heredity  and  personal  history,  the  general  phenomena  and  local 
appearance  of  a  fistulous  opening,  will  frequently  enable  one  to  predicate 
the  existence  of  tuberculosis,  but  the  fistula  itself  can  not  positively  be 
called  tubercular  without  the  corroborative  evidence  furnished  by  these 
means.  It  is  important,  therefore,  that  one  living  at  a  distance  from  labo- 
ratories should  prepare  himself  to  make  such  examinations,  and  be  able 
to  decide  with  a  certain  degree  of  promptness  the  pathological  nature  of 
any  fistula  with  which  he  has  to  deal.  One  should  not  presume  upon  a 
negative  result  in  physical  examination  as  proving  the  non-tubercular 
nature  of  fistula,  nor  should  he  conclude  that  it  is  tubercular  because 
there  is  a  hereditary  taint.  The  fistula  should  be  judged  from  its 
own  tissues.  Probabilities  should  not  be  relied  on  where  knowledge  is 
obtainable.  In  tuberculosis  and  carcinoma  this  can  be  done,  and  no 
fistula  should  be  treated  without  it.  In  syphilitic  fistula  the  histological 
examinations  are  not  so  certain,  though  they  may  confirm  the  clinical 
evidences. 

The  diagnosis  of  urinary  fistula  may  be  made  from  the  history  of  the 
case,  the  character  of  the  discharge,  the  preponderance  of  urethral  symp- 
toms, the  induration  in  front  of  the  transversus  perinei  muscles,  and  may 
be  corroborated  by  the  administration  of  a  capsule  of  methylene  blue  by 
the  mouth,  as  after  urination  the  fistulous  tract  will  be  stained  blue. 

Prognosis. — The  probable  outcome  of  any  given  fistula  will  depend 
upon  three  conditions:  first,  the  pathological  nature  of  the  fistula;  sec- 
ond, the  constitutional  condition  of  the  patient;  third,  the  amount  of 
tissue  involved. 

It  is  customary  in  books  upon  rectal  diseases  and  general  surgery 
to  describe  fistula  as  a  condition  most  amenable  to  treatment.  As  a 
matter  of  fact,  however,  a  very  large  percentage,  if  not  a  majority  of 
the  cases  of  fistula  operated  upon  in  hospitals  and  treated  by  general 
surgeons,  are  failures  so  far  as  cure  is  concerned.  A  search  of  the  hos- 
pital records  reveals  the  fact  that  while  nearly  all  the  cases  of  fistula 
treated  are  said  to  be  improved,  less  than  45  per  cent  out  of  3,196  cases 
collected  are  even  claimed  to  have  been  cured.  These  statistics  do  not 
distinguish  between  the  different  varieties  anatomically  or  pathologic- 


FISTULA  3T3 

ally,  and  therefore  no  positive  conclusions  can  be  drawn  from  them. 
It  is  reasonable  to  suppose,  however,  that  those  of  the  simple  subtegu- 
mentary  type  were  all  cured.  Assuming  this  to  be  true,  the  percentage  of 
failures  in  the  other  classes  will  be  largely  increased.  If  these  patients 
had  been  cured  there  is  no  doubt  that  they  would  have  been  entered  so 
upon  the  hospital  records,  and  therefore  it  is  concluded  that  the  treat- 
ment of  this  condition  in  general  hospitals  is  far  from  satisfactory. 

There  is  no  more  difl&cult  or  disappointing  condition  to  treat,  and 
in  giving  a  prognosis  one  must  always  bear  in  mind  the  three  conditions 
mentioned  above.    Why  fistulas  fail  to  heal  has  been  already  discussed. 

Cases  of  spontaneous  cure  have  been  reported  by  Bennett,  Ailing- 
ham,  Bodenhamer,  Edwards,  Ribes,  Velpeau,  and  others.  Bodenhamer 
(Med.  Record,  'N.  Y.,  1891,  vol.  i,  p.  354)  has  related  a  case  in  which 
he  examined  the  patient  and  determined  the  existence  of  a  complete 
ano-rectal  fistula  but  instituted  no  medical  or  surgical  treatment.  The 
patient  died  from  pneumonia  about  one  year  after  this  examination,  and 
the  autopsy  showed  a  simple  cicatricial  cord  throughout  the  old  tract 
measuring  about  3^  inches.  It  had  thus  been  obliterated  without  any 
treatment  whatever. 

The  writer  has  seen  2  cases  of  complete  subtegumentary  fistula  heal 
within  a  short  period  after  examination  with  a  probe.  In  these  cases 
the  tract  had  existed  in  one  case  three  weeks,  and  in  the  other  about 
two  months.  The  introduction  of  the  probe  seemed  to  start  up  a  healthy 
granulation,  and  thus  induced  healing.  A  number  of  cases  of  this  kind 
has  been  reported. 

While  such  facts  are  interesting,  it  would  be  trifling  with  a  patient's 
confidence  to  hold  out  any  hope  of  such  a  result  except  in  the  rarest 
instances.  The  length  of  time  required  to  cure  a  fistula  is  very  variable. 
When  it  can  be  dissected  out  and  the  wound  sutured,  if  primary  union 
takes  place  the  condition  will  be  cured  in  about  two  weeks;  but  when 
it  is  treated  by  the  open  method,  the  time  varies  from  two  weeks  to 
several  months;  three  to  six  months  is  no  unusual  time  for  the  healing 
of  extensive  fistulas,  even  where  the  operation  has  been  perfectly  per- 
formed. While  the  length  of  treatment  necessary  can  not  be  predicted 
in  any  given  case,  eventual  cure  can  be  confidently  proniised  in  uncom- 
plicated, benign,  and  non-tubercular  fistulas.  So  far  as  life  is  con- 
cerned, if  we  except  the  malignant  type,  the  prognosis  is  always  good, 
even  in  the  tubercular  variety,  if  unwise  interference  is  avoided.  This 
brings  up  the  subject  of  the  advisability  of  operating  in  such  cases. 

Operations  in  Tubercular  Fistula. — Here  again  the  distinction  is 
made  between  a  tubercular  fistula  and  a  fistula  in  the  tuberculous.  It 
seems  unnecessary  to  discuss  the  question  of  radical  operation  for  fistula 
in  well-established  cases  of  pulmonary  tuberculosis.    Where  it  is  of  the 


374  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

complex  variety  and  associated  with  much  pain  and  great  discharge,  thus 
occasioning  exhaustion  and  excessive  wear  upon  the  nervous  system,  a 
certain  amount  of  intervention  (just  sufficient  to  relieve  these  symptoms) 
may  be  justified,  but  it  should  not  be  undertaken  with  the  hope  of  curing 
the  fistula.  The  majority  of  patients  in  this  condition  will  succumb  to 
the  pulmonary  disease  before  healing  of  the  local  lesion  can  be  obtained. 
It  may  be  set  down,  therefore,  as  an  axiom  that  fistulas  in  well-developed 
cases  of  pulmonary  tuberculosis  should  be  interfered  with  as  little  as  is 
compatible  with  local  comfort.  They  usually  cause  very  little  disturb- 
ance if  properly  drained,  and  the  shock  consequent  upon  operations,  the 
loss  of  blood  however  slight,  the  influence  of  general  anaesthesia  however 
skilfully  administered,  add  nothing  to  the  strength  of  the  patient.  His 
well-being  in  this  disease  depends  altogether  upon  his  power  of  resist- 
ance to  the  invasion  of  the  bacilli.  Whatever  weakens  this  power  of 
resistance  decreases  his  hold  upon  life,  and  should  be  avoided  as  far  as 
possible.  Operations  upon  this  class  of  cases  have  brought  the  operative 
treatment  of  fistula  into  disrepute,  and  one  should  therefore,  as  a  rule, 
abstain  from  them  in  cases  of  established  pulmonary,  genito-urinary,  or 
intestinal  tuberculosis. 

In  the  matter  of  tubercular  fistulas,  however,  the  subject  is  ap- 
proached from  another  point.  Here  there  is  a  localized  tuberculosis, 
and  it  is  a  question  as  to  whether  these  foci  of  disease  can  be  eradicated 
or  not.  If  the  radical  removal  of  the  infected  focus  is  feasible,  no  sur- 
geon would  hesitate  for  a  moment  to  say  that  it  should  be  done  as  quickly 
as  possible,  provided  that  the  patient  is  otherwise  healthy.  Formerly, 
operations  upon  fistula  were  opposed  by  many  surgeons  on  the  ground 
that  they  were  salutary  in  that  the  discharge  carried  off  the  infectious 
germs;  that  the  bacilli  circulating  in  the  blood  found  at  this  point  a 
convenient  exit  from  the  body,  and  that  the  closure  of  this  would  only 
dam  them  up  in  the  system  and  thus  cause  infection  elsewhere.  With 
the  modern  views  of  pathology  such  a  doctrine  is  no  longer  tenable. 
There  is  no  reason  to  suppose  that  a  purulent  discharge  from  a  fistula 
in  ano  is  more  salutary  than  one  from  tubercular  glands  or  bones,  and 
yet  every  surgeon  to-day  advocates  the  removal  of  these.  -  Eadical  re- 
moval, however,  and  not  partial,  is  what  is  done  in  these  cases.  For 
some  years  the  author  has  opposed  the  open  operation  for  tubercular 
fistulas  upon  the  ground  that  an  incision  into  the  perifistulous  tissues 
only  opens  the  channels  of  absorption  to  infection  by  the  tubercle  bacilli 
present  in  the  tract;  and  if  a  tubercular  fistula  must  be  operated  upon 
by  the  simple  method  of  incision  it  had  far  better  be  left  to  its  own 
course. 

If  one  will  refer  to  the  section  upon  the  pathology  of  tuberculosis  he 
will  observe  that  around  these  fistulous  canals,  outside  of  the  lining 


FISTULA 


io 


> 


layer  of  granulation,  there  is  a  gradually  increasing  fibrous  or  cicatricial 
wall  throughout  their  extent  (Fig.  135).  It  ivill  he  ohserved  also  that  the 
farther  one  passes  from  the  canal  outward  into  this  cicatricial  tissue  the 
fewer  are  the  tubercle  hacilli  and  giant-cells,  and  they  disappear  alto- 
gether in  the  densest  portion;  this  condition  exhibits  an  effort  upon  the 
part  of  Nature  to  protect  herself  against  the  invasion  of  the  pathological 
germs  by  a  well-defined,  limiting  wall,  which,  if  the  fistula  be  properly 
drained,  will  limit  the  disease  in  the  large  majority  of  instances,  at 
least  for  long  periods.  Break  down  that  wall  by  incision  or  deep  curet- 
ting, and  the  lymphat- 


ic circulation  is  opened 
for  the  admission  of 
this  virulent  bacillus. 
These  facts  can  not  be 
disputed,  but  many 
competent  surgeons 
and  writers  still  advo- 
cate this  method  of  op- 
eration because  a  large 
number  of  supposed  tu- 
bercular fistulas  have 
been  cured  by  it  with- 
out the  development  of 
generalized  tuberculo- 
sis. In  the  large  ma- 
jority of  these  cases  the 
tubercular  nature  of 
the  fistula  has  not  been 
demonstrated.  But,  ad- 
mitting that  all  the 
cases  reported  were  tuberculous,  they  do  not  disprove  the  possibility  of 
generalization  taking  place,  and  the  relief  obtained  has  not  justified  the 
risk.  Hartmann's  196  cases  do  not  prove  anything  contrary  to  this 
theory,  for  he  either  dissected  out  the  entire  tuberculous  focus  and 
united  the  healthy  tissues  by  sutures,  or  he  opened  the  fistulous  tract 
with  a  Paquelin  cautery,  thus  sealing  up  the  lymphatics  and  destroying 
the  tubercle  bacilli  by  cauterization  with  a  platinum  knife  heated  to 
a  white  heat.  According  to  his  own  statements  the  cicatricial  wall  was 
never  broken  down,  nor  were  the  healthy  perifistulous  tissues  opened 
even  by  the  heated  knife.  These  are  very  different  procedures  from 
laying  the  parts  open  and  incising  the  fibrous  wall  in  all  directions  with 
a  knife;  they  attempt  to  remove  or  destroy  the  pathological  element  en- 
tirely, and  this  is  in  keeping  with  our  proposition. 


Fi&.  125. — Teansveese  Section  of  TuBEEcirLAE  Fistula 

(PHOTOillCEOGEAPH). 


376  THE  ANUS,   RECTUM,  AXD  PELVIC  COLON 

On  the  other  hand,  there  are  a  certain  number  of  positive  facts  -which 
show  the  danger  of  laying  open  these  tubercular  fistulas  by  the  knife 
and  curetting  their  cicatricial  walls,  as  is  advised  in  the  operation  of 
Salmon.  The  writer  himself  has  seen  five  cases  in  which  tuberculosis 
either  of  the  lungs  or  of  the  peritonaeum  rapidly  followed  operations  for 
tubercular  fistulas.  In  one  case  an  Italian  boy,  who  had  suffered  from 
a  fistula  for  over  two  years,  was  brought  to  the  Polyclinic  Hospital 
November  10,  1897,  and  was  examined  by  Dr.  Page,  one  of  the  most 
expert  diagnosticians  of  this  city.  No  evidence  whatever  of  pulmonary 
tuberculosis  could  be  detected.  He  had  no  kidney,  liver,  or  bladder 
symptoms  which  would  indicate  involvement  of  these  organs.  The  fis- 
tula was  a  typical  tubercular  one  in  its  appearance,  and  consisted  of  a 
straight,  narrow  canal  leading  from  a  point  about  1  inch  from  the  margin 
of  the  anus,  upward  and  inward  through  the  external  sphincter  and  the 
mucous  membrane  into  the  rectum  about  ^  an  inch  above  the  ano-rectal 
line.  Tubercle  bacilli  were  found  in  granulations  scraped  out  of  the 
tract.  The  fistula  was  laid  open,  curetted,  and  cauterized  with  Calvert's 
carbolic  acid.  The  cicatricial  tissue  surrounding  the  tract  was  then 
incised  in  several  directions  in  order  to  hasten  its  absorption  and  to 
establish  healthy  granulation.  The  wound  granulated  and  proceeded 
to  heal  as  promptly  as  in  ordinary  fistulas.  At  the  end  of  six  weeks, 
however,  the  patient  developed  acute  pulmonary  tuberculosis  and  died 
a  little  over  four  months  after  the  operation.  In  the  meantime  the 
fistula  had  perfectly  healed. 

Another  instance  was  in  a  patient  referred  to  the  writer  by  Dr. 
Sherwell,  of  Brookl}Ti.  He  had  suffered  from  irritation  of  his  rectum 
for  several  months;  there  was  always  a  certain  amount  of  discharge,  but 
never  any  external  opening  which  could  be  discovered;  the  condition 
gave  him  no  pain  excejDt  after  faecal  passages,  which  brought  on  symp- 
toms of  fissure  in  ano.  An  examination  of  the  lungs,  kidneys,  bladder, 
prostate,  and  the  other  organs  failed  to  reveal  any  evidence  of  constitu- 
tional disease.  The  rectum  and  sigmoid  showed  nothing  pathological 
save  a  small  ulcer  in  the  posterior  commissure  about  |  of  an  inch  from 
the  cutaneous  margin.  From  this  ulcer  there  extended  downward  and 
outward  a  fistulous  tract  to  the  extent  of  about  ^  an  inch.  The  ulcer 
was  crenated  and  irregular  in  shape,  the  edges  undermined,  and  dis- 
charged a  scant  sero-purulent  fiuid  in  which  no  tubercle  bacilli  could 
be  found.  The  fistulous  tract  and  the  base  of  the  ulcer  were  indurated 
but  not  nodular. 

He  was  admitted  to  the  Polyclinic  Hospital  on  October  5,  1900.  On 
October  6th  an  operation  was  performed  by  first  incising  and  then  dis- 
secting out  the  ulcer  and  fibrous  tissue.  As  the  inflammatory  process 
did  not  appear  tubercular,  and  was  very  shallow,  it  was  concluded  that 


FISTULA  377 

the  patient  would  suffer  less  from  spasm  of  the  sphincters  if  the  wound 
were  left  open  to  heal  by  granulation.  He  never  had  an  unfavorable 
S3n2iptom  while  in  the  hospital,  and  on  October  13th  the  wound  looked 
so  healthy  and  the  patient  felt  so  comfortable  that  he  was  allowed  to  go 
home,  with  instructions  to  present  himself  for  observation  occasionally. 
On  October  16th  he  felt  a  sensation  of  chilliness  and  malaise,  and  later 
he  was  seized  with  a  distinct  rigor.  From  this  tune  on  he  was  never 
without  some  temperature;  he  rapidly  failed  in  strength,  and  finally 
died  from  tubercular  peritonitis  on  January  5th.  The  patient,  according 
to  his  doctor  and  family,  had  never  had  a  symptom  of  peritoneal  trouble 
before  this  operation.  Microscoi^ic  examination  of  the  specimen  re- 
moved revealed  no  tubercle  bacilli,  but  there  were  some  giant-cells  sur- 
rounded by  embryonic  tissue  which  the  author  believes  proved  the 
tubercular  nature  of  the  ulcer. 

A  third  case,  W.  D.,  aged  twenty-seven,  presented  himself  at  the 
clinic  on  January  2,  1901,  with  the  history  of  having  suffered  from  a 
perirectal  abscess  some  two  months  previously.  This  had  failed  to  heal, 
and  caused  him  considerable  annoyance.  Examination  showed  the  exist- 
ence of  a  horseshoe  fistula  opening  externally  u^^on  one  side  and  enter- 
ing the  rectum  at  the  posterior  commissure  about  ^  an  inch  above  the 
margin  of  the  anus.  The  fistulous  tract  upon  the  opposite  side  was 
not  open  externally  but  discharged  through  the  rectal  opening.  A 
careful  examination  was  made  of  the  patient's  lungs,  throat,  kidneys, 
bladder,  and  prostate  with  negative  results;  he  had  no  temperature,  no 
cough,  and  no  symptom  of  pulmonary  disease  at  the  time  he  was  ad- 
mitted to  the  hospital.  The  discharge  from  the  abscess  was  examined 
by  the  microscope  and  no  tubercle  bacilli  were  found;  the  culture 
test  was  not  made.  An  effort  to  reduce  the  discharges  by  irrigation  was 
unsuccessful,  and  therefore  it  was  advised  that  the  tract  be  opened.  This 
was  done  February  1,  1901,  under  the  strictest  antiseptic  precautions. 
The  parts  were  dressed  with  ichthyol  and  glycerin  after  having  been 
washed  out  thoroughly  with  bichloride  solution.  Bacilli  were  found  in 
a  section  of  tissue  removed  at  the  time  of  operation.   . 

No  unusual  symptom  followed  save  a  slight  elevation  of  temperature 
during  the  first  twenty-four  hours.  After  this  the  patient  felt  perfectly 
well  and  began  to  improve  in  his  looks,  appetite,  and  general  condition. 
In  four  weeks  the  wound  granulated  and  was  filling  up,  but  the  patient 
began  to  lose  his  appetite  and  feel  exhausted,  especially  in  the  morning. 
On  February  10th  he  had  a  marked  hgemoptysis  which  nearly  cost  him  his 
life,  and  from  that  time  forward  he  rapidly  developed  tuberculosis  of 
the  right  apex  with  all  the  concomitant  symptoms.  At  the  same  time 
under  antiseptic  dressings  and  treatment  the  fistulous  wound  on  one  side 
practically  healed,  but  on  the  other,  after  healing,  it  broke  down  and 


378  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

had  the  typical  appearance  of  a  tubercular  ulcer.  He  was  taken  from 
the  hospital  and  it  was  reported  later  that  he  died  within  six  months. 
It  may  be  said  that  these  cases  are  accidental,  and  that  the  constitu- 
tional symptoms  would  have  manifested  themselves  had  no  operation 
been  done,  but  there  is  no  proof  of  this.  In  the  first  case  the  patient 
had  carried  his  fistula  for  two  years  witliout  any  pulmonary  implication, 
and  yet  developed  it  within  a  short  time  after  operation  by  the  open 
method.  In  the  second  case  the  patient  had  suffered  from  his  rectal 
ulceration  or  fistula  for  over  six  months  without  any  constitutional  impli- 
cation, and  yet  he  developed  tubercular  peritonitis  within  two  weeks 
from  the  time  of  the  open  operation.  In  the  third  case  the  period  dur- 
ing which  the  patient  had  suffered  from  fistula  was  no  doubt  brief,  but 
at  the  same  time  it  was  considerably  longer  than  that  between  the  opera- 
tion and  the  development  of  the  pulmonary  symptoms. 

Quite  a  number  of  patients  suffering  from  pulmonary  tuberculosis 
have  been  seen  who  are  very  positive  that  they  never  had  any  cough  or 
pulmonary  affection  until  after  operative  interference  with  their  fistulas, 
and  it  is  well  known  that  the  above  cases  can  be  supported  by  many  oth- 
ers reported  in  medical  literature.  The  results,  therefore,  do  not  justify 
the  risks  of  open  incision. 

AVhere  the  tubercular  fistula  can  be  entirely  removed,  and  the  wound 
closed  by  immediate  suture,  the  probabilities  of  complete  cure  are  very 
encouraging;  but  when  the  fistulous  tract  is  so  deep  and  tortuous,  or  so 
great  in  extent  that  immediate  closure  is  impossible,  operation  by  the 
heated  knife  is  to  be  preferred.  In  the  majority  of  instances  the  patient 
will  be  more  benefited  by  providing  necessary  drainage  and  cauterizing 
the  lining  membrane  of  the  fistulous  tract  than  by  lajdng  it  entirely 
open;  but  even  with  the  cautery  the  surrounding  cicatricial  wall  should 
not  be  broken  down  unless  complete  excision  and  immediate  suture  can 
be  practised. 

Treatment. — The  treatment  of  fistula  consists  in  the  obliteration  of 
the  chronic,  suppurating  tracts,  either  by  the  process  of  granulation  or 
by  excision  with  innnediate  suture.  The  first  method  is  that  which  is 
generally  employed.  The  means  of  inducing  this  granulation  may  be 
described  as  the, conservative  and  radical. 

Conservative  or  Non-operative  Methods. — By  these  terms  we  do  not 
mean  a  method  without  any  incision ;  every  fistula  is  practically  a  clironic 
abscess,  and  it  is  hopeless  to  attempt  to  cure  them  without  establishing 
complete  drainage;  an  incision  to  accomplish  this  is  therefore  always 
necessary. 

In  simple,  blind  external  fistulas,  complete  drainage  with  curettage 
or  cauterization  of  the  tract  and  dilatation  of  the  sphincter  will  always 
result  in  a  cure  without  further  operative  interference.     Where  it  does 


FISTULA  379 

not,  one  may  very  reasonably  conclude  that  there  is  some  connection 
with  the  rectum  through  which  reinfection  is  taking  place,  or  a  patho- 
logical condition  of  the  fistula  itself,  which  destroys  healthy  granulation. 
In  a  number  of  blind  external  fistulas  cure  may  be  effected  by  distending 
the  cavity  with  a  saturated  solution  of  nitrate  of  silver  (960  grains  per 
fluid  ounce),  and  after  this  has  remained  for  two  or  three  minutes  the 
parts  are  cocainized,  the  opening  is  enlarged  so  as  to  give  perfect  drain- 
age to  the  cavity,  and  the  sphincter  is  stretched  gently  either  with  the 
fingers  or  with  the  rectal  dilator.*  Thorough  dilatation  of  this  muscle 
is  better,  but  it  can  not  ordinarily  be  accomplished  without  general 
anesthesia.  By  the  use  of  nitrous-oxide  gas  or  ethyl  chloride  it  is 
possible  to  perform  this  operation  in  the  clinic  upon  walking  cases,  but 
in  private  practice  one  would  scarcely  dare  give  even  these  general 
aneesthetics  and  allow  the  patients  to  go  home  immediately  afterward. 

Bennett  states  that  he  has  cured  a  large  number  of  complete  fistulas 
by  the  injection  of  concentrated  solutions  of  nitrate  of  silver  into  them, 
and  Goodsall  and  Miles  advocate  this  method  of  treatment  in  all  cases 
in  which  the  inner  opening  is  above  the  internal  sphincter.  The  dis- 
tention of  the  cavity  by  the  solution  of  silver  should  always  be  followed 
by  the  enlargement  of  the  external  opening  in  order  that  the  necrosed 
tissue  and  increasing  discharge  due  to  that  cauterant  may  have  a  free  out- 
let. Formerly  it  was  a  practice  to  inject  these  tracts  with  equal  parts  of 
iodine  and  carbolic  acid,  which  gave  some  very  satisfactory  results.  Pure 
tincture  of  iodine  and  tincture  of  rhatany,  solutions  of  copper  sulphate, 
the  solid  stick  of  nitrate  of  silver,  and  many  other  cauterizing  agents 
have  been  employed  from  time  immemorial  in  this  method  of  treatment. 
On  the  whole,  however,  the  saturated  solution  of  nitrate  of  silver  is  the 
most  satisfactory.  It  is  better  than  the  solid  stick,  because  it  reaches  all 
the  diverticuli  and  tortuous  tracts,  whereas  the  stick  only  applies  itself 
to  the  accessible  portions  of  the  abscess  cavity,  and  it  is  very  likely  to 
break  off  when  it  is  introduced  into  a  deep  tract.  In  narrow,  subtegu- 
mentary  fistulas,  both  of  the  complete  and  blind  external  variety,  cures 
may  be  effected  by  the  introduction  of  a  probe  upon  which  nitrate  of 
silver  has  been  fused.  The  discharge  and  irritation  are  increased  for  a 
few  days  following  this  treatment,  after  which  healthy  granulation 
springs  up  and  the  tract  becomes  obliterated.  After  the  injection  or 
application  of  the  nitrate  of  silver,  the  slough  which  it  produces  will 
all  come  away  in  about  ten  days,  and  ordinarily  a  healthy  granulation 
will  be  established.  If  this  is  not  the  case,  the  application  should  be 
repeated.     Where  the  granulation  is  established,  however,  the  applica- 


*  Powell  advocates  the  use  of  piu-e  carbolic  acid  instead  of  nitrate  of  silver,  and 
claims  to  have  obtained  excellent  results  from  it  (Amer.  Surg,  and  Gynseol.,  April, 
1902). 


380  THE  ANUS,   RECTUM,   AND  PELVIC  COLON 

tion  should  not  be  repeated  for  two  or  three  weeks.  It  may  be  necessary 
to  inject  the  sohition  three  or  four  times  at  such  intervals  before  a  cure 
is  accomplished. 

When  the  fistula  is  of  the  complete  variety,  it  is  well  to  inject  a  little 
sweet-oil  into  the  rectum  before  the  nitrate  of  silver  is  introduced  into 
the  fistulous  cavity,  in  order  to  prevent  the  drug  from  irritating  the 
mucous  membrane  if  it  should  pass  through  into  the  intestine.  Good- 
sail  and  Miles,  whose  large  experience  gives  weight  to  their  opinion. 


Fig.  126. — Allinoham's  LiiiATUitE-cARitiER. 


in  speaking  of  this  method  of  treatment  for  fistulas  opening  into  the 
rectum  above  the  internal  sphincter,  say:  "  When  after  repeated  applica- 
tions the  sinus  still  remains  unhealed,  it  is  better  to  leave  it  alone  than 
to  incur  the  risk  of  probable  incontinence  by  the  division  of  the  internal 
sphincter  for  the  cure  of  the  fistula.  In  fact  the  patient  should  be 
urged  to  tolerate  the  persistency  of  his  fistula  rather  than  take  the  risk 
of  loss  of  the  power  of  control  over  the  contents  of  the  rectum."  This 
is  undoubtedly  a  too  conservative  view;  in  cases  in  which  radical  excision 
with  immediate  suture  is  possible,  there  is  no  reason  why  the  internal 
sphincter  should  not  be  just  as  successfully  sutured  as  the  external. 
The  advisability  of  testing  the  methods  of  local  treatment  before  resort- 
ing to  an  operation  which  involves  the  cutting  of  the  sphincters  can  not 
be  contested;  they  not  only  succeed  in  many  cases,  but  they  possess  the 
advantage  of  finally  decreasing  the  amount  of  discharge  and  reducing 
the  size  of  the  fistulous  tract  to  such  an  extent  that,  if  they  fail  to  cure, 
the  parts  are  in  a  much  better  condition  afterward  for  radical  operation. 
In  the  treatment  of  complete  fistulas  by  this  method,  it  is  important 
that  the  stools  be  kept  well  formed,  because  if  thin  and  watery  they  will 
escape  through  the  internal  opening  and  prevent  healing. 

It  is  the  practice  of  certain  itinerant  specialists  to  wash  out  the 
abscess  cavity  with  peroxide  of  hydrogen  until  the  effervescence  caused 
by  it  has  ceased.  After  this  they  irrigate  the  fistulous  cavity  with  a 
solution  of  bichloride  of  mercury,  carbolic  acid,  or  nitrate  of  silver,  and 
repeat  this  treatment  every  second  or  third  day.  Wlien  the  discharge 
has  been  largely  controlled,  they  dilate  the  mouth  of  the  fistula  with 
forceps  or  lay  it  open  under  the  anaesthetic  action  of  cocaine,  and  thus 
obtain  free  drainage.  The  method  is  rational,  and  there  is  no  doubt 
that  they  succeed  in  curing  a  great  many  cases  by  this  method. 

Where  these  conservative  methods  fail  to  effect  a  cure  after  six  or 
eight  weeks'  trial  one  should  then  attempt  radical  operation.     Before 


FISTULA 


381 


doing  this,  however,  in  fact  before  attempting  any  treatment  whatever, 
one  should  satisfy  himself  absolutely  with  regard  to  the  pathological 
nature  of  the  fistula,  and  if  tuberculosis,  syphilis,  or  malignant  disease 
exists,  he  shou.ld  be  guided  by  the  principles  laid  down  in  the  preceding 
section  of  this  chapter. 

The  Ligature. — The  treatment  of  fistulas  by  the  use  of  the  ligature 
is  classed  by  many  among  the  conservative  or  non-operative  methods. 
The  only  groimd  for  this  is  in  the  fact  that  the  cutting  is  done  without 
a  knife  and  there  is  no  hsemorrhage.  It  accomplishes  exactly  the  same 
division  of  tissues  as  is  done  by  incision,  only  in  a  miich  slower  and 
more  painful  manner.  It  has  been  employed  since  the  time  of  Hip- 
pocrates. Silk,  linen,  and  elastic  threads  have  all  been  used,  but  at 
present  only  the  rubber  ligature  is  employed;  this  was  first  utilized 
for  this  purpose  by  Lee  and  Holthouse;  Dittel,  of  Vienna,  afterward 
employed  it,  and  Allingham  and  Bodenhamer  adopted  the  method 
after  him. 

The  principle  upon  which  the  method  rests  consists  in  the  cut- 
ting through  of  the  overlying  tissues  by  the  continuous  contraction 
of  the  elastic  thread.  It 
was  at  one  time  supposed 
that  healthy  granulation 
was  established  in  the  fis- 
tulous tract  and  followed 
the  ligature  out  as  it  cut 
its  way  through  by  slow 
attrition,  thus  obliterating 
the  tract  at  the  same  time. 
This  claim  has  been  aban- 
doned, however,  and  all 
who  employ  this  method 
now  use  the  small,  round, 
solid-rubber  ligature.  It  is 
passed  through  the  fistu- 
lous tract  either  with  for- 
ceps or  by  a  specially  de- 
vised instrument  (Fig.  126) 
known  as  the  ligature-car- 
rier.     T\Tiere  the  fistulous 

tract  passes  beneath  the  skin  an  incision  should  be  made  through  this 
tissue,  for  where  this  is  not  done  the  pain  is  almost  unbearable. 

Having  passed  the  ligature  through  the  fistula,  a  small  metal  shield 
or  perforated  shot  is  passed  over  the  two  ends  and  fastened  by  pressure 
with  a  strong  forceps  while  the  rubber  is  fully  extended  (Fig.  127).    The 


Fig.  127.- 


-LlGATUEE    PASSED    THROUGH    FlSTULA   AND 
SECIIEED. 


382  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

advantages  claimed  for  this  method  are  that  it  occasions  little  pain, 
does  not  confine  the  patient,  is  free  from  the  dangers  of  hemorrhage, 
and  a  certain  number  will  submit  to  it  who  absolutely  refuse  to  have 
any  cutting  operation  done.  Allingham  says:  "  Those  ^\'ho  find  any 
difficulty  in  getting  the  ligature  to  cut  quickly  and  painlessly  are 
ignorant  of  the  proper  method  of  applying  it ";  but  unfortunately  he 
does  not  give  any  description  of  this  proper  method.  In  the  author's 
experience  it  has  proved  successful  in  curing  the  few  cases  in  which  it 
has  been  applied;  but,  so  far  as  the  patient's  going  about  with  it  or  suf- 
fering no  pain  is  concerned,  the  claims  of  its  advocates  can  not  be  sub- 
stantiated. The  experience  of  every  patient  that  has  been  treated  by 
this  method  is  that  they  have  suffered  greatly  and  often  been  confined 
to  their  beds  while  the  ligature  was  cutting  through;  in  two  cases  it  has 
been  necessary  to  remove  it  on  account  of  the  pain.  The  only  real 
advantage  wliich  the  method  seems  to  possess  over  that  of  incision  con- 
sists in  the  absence  of  haemorrhage.  With  the  numerous  instruments 
at  one's  command  by  which  bleeding  can  be  controlled,  this  recom- 
mendation carries  little  weight  except  in  cases  where  the  internal  open- 
ing is  very  high  in  the  rectum.  One  never  sees  at  the  present  day 
uncontrollable  ha?morrhage  in  operations  for  this  condition;  but,  for 
the  sake  of  argument,  admitting  that  the  ligature  does  obviate  this 
possible  danger,  this  advantage  is  more  than  counterbalanced  by  the 
objections  to  it. 

In  its  employment  no  antiseptic  precautions  are  taken,  and  there 
is  no  guard  against  infection  of  the  freshly  cut  tissues  from  the  bacteria 
always  present;  it  is  followed  by  a  dense,  hard  cicatrix;  it  only  accom- 
plishes after  days  what  can  be  done  with  a  knife  or  tliermo-cautery  in 
a  few  moments;  and  finally,  after  the  fistulous  tract  has  been  cut  through 
by  this  method,  it  will  often  be  necessary  to  lay  open  and  enlarge  lateral 
tracts  with  the  knife  or  scissors.  On  the  whole,  therefore,  if  the  tissues 
intervening  between  the  rectum  and  the  fistulous  tract  are  to  be  cut 
through  at  all,  it  seems  preferable  that  it  should  be  done  as  rap- 
idly as  possible  under  antiseptic  precautions  and  circumstances  which 
will  allow  the  whole  suppurative  tract  to  be  laid  open  and  treated 
at  one  time  without  having  the  operation  divided  into  two  or  three 
sittings. 

If  the  application  is  technically  carried  out  and  the  ligature  always 
passed  through  the  internal  pathological  opening,  there  is  no  doubt  that 
it  will  result  in  a  cure  in  the  large  majority  of  cases.  The  -finding  and 
laying  open  of  the  pathological  tract  leading  into  the  rectum  is  the  secret  of 
success  in  the  treatment  of  fistula,  whether  it  is  done  hy  the  ligature,  l-nife, 
ecraseur,  or  cautery.  It  is  difficult,  sometimes  impossible,  to  trace  long, 
tortuous  tracts  with  the  ligature  carrier,  and  puncturing  the  rectal  wall 


FISTULA 


383 


at  the  highest  point  of  the  cavity  so  as  to  make  a  way  for  the  thread  is 
sure  to  result  in  failure  here,  just  as  it  does  in  operation  by  incision, 
because  a  part  of  the  fistula  is  left  untouched  (Fig.  128). 

It  has  been  claimed  that  faecal  incontinence  is  much  less  likely  to 
occur  from  this  method  than  from  operation  by  incision.  Incontinence 
depends  upon  the  amount  of  muscular  tissue  cut  and  the  imperfect  ap- 
position of  the  fibers  when  they  reunite.  If  the  muscle  is  cut  square- 
ly across  by  a  sharp 
knife  it  will  be  less 
likely  to  occur  than  if 
it  is  done  by  the  crush- 
ing process  of  a  liga- 
ture, for  the  width  of 
the  cicatrix  will  be 
less.  There  is  neither 
fact  nor  reasonable 
theory  to  substantiate 
this  claim  for  the  liga- 
ture. 

The  writer  is  well 
aware  of  the  fact  that 
a  number  of  fistulas 
have  been  cured  by 
the  ligature  which  had 
been  unsuccessful  ly 
operated  upon  by  in- 
cision. The  explana- 
tion of  these  cases  lies  simply  in  the  fact  that  the  operators  found  the 
pathological  opening  and  cut  it  through  with  the  ligature.  Had  the 
original  operators  found  this  orifice  and  cut  it  through  with  the  knife, 
the  operations  would  have  been  equally  successful.  It  is  simply  a  ques- 
tion here  to  find  and  remove  the  source  of  infection  by  laying  open  and 
draining  the  entire  pathological  tract. 

In  those  cases  where  the  internal  opening  is  3  to  4  inches  above  the 
sphincter  muscle,  the  elastic  ligature  is  a  safe  and  reliable  method  of 
laying  open  the  tract.  The  advisability  of  opening  such  a  tract  at  all, 
however,  is  by  no  means  settled.  As  quoted  above,  Goodsall  and  Miles  . 
absolutely  oppose  such  an  operation;  Quenu  and  Hartmann  believe  that 
incision  is  a  dangerous  procedure  under  such  circumstances;  they  hold 
that  complete  excision  with  immediate  suture  is  preferable,  and  the 
author  agrees  with  them. 

Fistulotomy. — One   other  conservative   method    of  treating  fistulas 
should  be  mentioned.     It  consists  practically  in  scarifying  or  incising 


Fig.  128. — Fistula  in  which  the  Internal  Opening  {A)  is 
IN  A  Different  Quadrant  from  that  in  "which  the  Ab- 
scess Cavity  {B)  is  Nearest  the  Rectal  Wall,  and  show- 
ing how  perforating  the  Wall  at  the  Latter  Point  and 
incising  the  Gut  down  to  the  Anus  bt  Ligature  ok 
Knife  will  leave  a  Part  of  the  Pathological  Tract 
untouched. 


384  THE   AxNUS,  RECTUM,  AND  PELVIC  COLON 

the  walls  of  the  fistulous  tract.  It  may  be  done  with  a  blunt-pointed 
tenotome  or  the  fistulotome  of  Mathews  (Fig.  129).  Fistulotomy  is  ap- 
plicable only  to  comparatively  straight  and  narrow  fistulas.  It  is  based 
on  the  same  principle  as  internal  urethrotomy,  i.  e.,  an  instrument  carry- 
ing a  concealed  knife  is  introduced  to  the  deepest  portion;  the  knife  is 
then  thrust  out  and  with  a  quick  motion  it  is  withdrawn,  thereby  incising 

^jT —         ■      ■ -30^^3)0^ 

Fm.  129. — Mathews's  Fistulotome.  , 

the  walls  of  the  fistula.  This  being  done  frequently  scarifies  the  tract 
in  all  its  circumference.  The  operation  may  have  to  be  repeated  several 
times  before  a  cure  is  obtained. 

The  claims  made  for  this  procedure,  that  it  dissipates  fear,  avoids 
haemorrhage,  does  not  involve  the  sphincter,  and  requires  no  detention 
from  business,  are  chimerical  and  likely  to  mislead  the  inexperienced. 
Blind  incision  into  vascular  areas  can  not  possibly  be  free  from  the 
danger  of  hsemorrhage,  and  being  made  through  infected  tissues  it  is 
also  likely  to  induce  sepsis.  No  adequate  drainage  is  established  by  it, 
and  it  may  be  followed  by  burrowing  or  collateral  abscesses.  Its  field 
is  very  limited,  it  requires  a  special  instrument,  and,  finally,  its  results 
are  not  comparable  to  treatment  by  nitrate  of  silver,  because  it  does  not 
improve  the  condition  of  the  parts  for  radical  operation  if  this  should 
become  necessary. 

Operative  Treatment  of  Fistula. — Of  the  operative  methods,  the  three 
which  deserve  consideration  are  incision,  excision,  and  excision  with  im- 
mediate suture. 

Each  of  these  should  be  undertaken  with  the  most  perfect  surgical 
technique.  The  patient  should  be  as  carefully  prepared  and  the  rules  of 
antisepsis  as  perfectly  followed  as  in  any  major  operation.  Antiseptic 
methods  are  employed  here  because  the  field  is  already  infected  and 
asepsis  is  impossible. 

The  Preparation  of  the  Patient. — The  best  results  will  be  obtained  in 
those  cases  in  which  the  fistula  has  been  treated  by  peroxide  of  hydrogen 
and  nitrate  of  silver  until  the  purulent  discharge  has  practically  ceased 
and  the  cavity  contracted  as  much  as  possible.  When  the  time  and  cir- 
cumstances of  the  patient  permit,  this  should  always  be  carried  out. 
The  actual  preparation  of  the  patient  for  operation  is  practically  the 
same  in  all  the  different  methods.  The  bowels  should  be  thoroughly 
cleaned  out  and  the  patient  put  on  a  limited  nitrogenous  diet  thirty-six 
hours  before  the  operation.  Purgation  should  have  ceased  entirely  be- 
fore the  operation  is  undertaken. 


FISTULA  385 

Along  with  the  preparatory  treatment  one  may  institute  an  attempt 
at  intestinal  antisepsis  by  the  administration  of  beta-naphthol,  salol, 
boric  acid,  or  sulpho-carbolate  of  zinc.  While  it  is  impossible  to  obtain 
absolute  asepsis  of  the  intestinal  tract,  there  is  no  doubt  that  cases 
treated  by  this  preliminary  preparation  have  less  intestinal  disturbance 
and  sepsis  than  those  operated  upon  without  it.  On  the  evening  before 
operating  a  large  soapsuds  enema  should  be  administered,  and  when  this 
has  been  passed  the  perianal  region  should  be  carefully  shaved,  scrubbed 
with  green  soap,  and  dressed  with  absorbent  gauze  moistened  in  a  solu- 
tion of  bichloride  of  mercury  (1  to  2,000).  This  dressing  should  be  kept 
moist  and  retained  in  situ  until  the  operation  begins.  Two  hours  before 
the  operation  itself  an  enema  of  about  1  pint  of  25-per-cent  peroxide  of 
hj^drogen  solution  should  be  given. 

The  anaesthetic  employed  will  depend  ripon  the  condition  of  the 
patient  and  the  extent  of  the  fistula.  "Where  it  is  proposed  simply  to 
incise  it,  the  parts  may  be  anggsthetized  by  the  hypodermic  injection  of 
cocaine;  in  the  majority  of  subtegumentary  fistulas  this  is  all  that 
will  be  necessary.  In  cases  where  there  are  extensive  fistulas  that 
require  large  dissection  and  dilatation  of  the  sphincters,  general  anaes- 
thesia is  much  more  satisfactory.  Where  it  is  not  contraindicated 
by  cardiac  conditions^  chloroform  is  preferable  to  ether  in  operations 
upon  the  rectum  on  account  of  the  slight  amount  of  nausea  and  retch- 
ing which  follow  it.  Ethyl  chloride  or  kelene  is  an  excellent  anaes- 
thetic for  short  operations,  and  as  an  adjuvant  to  the  administration 
of  ether  it  is  very  useful,  but  it  is  not  satisfactory  in  extensive  opera- 
tions on  account  of  the  fact  that  it  does  not  relax  the  muscles  suffi- 
ciently. 

A  very  satisfactory  method  is  spinal  cocainization,  because  there  is 
less  oozing  from  the  vessels,  and  after  the  first  few  minutes  when  nausea 
exists  the  patient  is  more  quiet,  the  sphincter  miiscles  more  relaxed,  and 
there  is  absolutely  no  pain;  furthermore,  in  this  method  of  angesthesia 
the  rectum  sometimes  becomes  insensitive  before  the  feet  and  legs.  No 
vomiting  or  straining  to  dislodge  the  dressing  follows  it,  and  the  anal- 
gesic effect  continues  for  several  hours  afterward,  thus  contributing  to 
the  comfort  of  the  patient.  There  is  generally  some  headache  on  the 
following  day,  but  this  is  not  very  severe.  The  remote  effects  of  this 
method  have  not  yet  been  determined,  and  consequently  it  is  not  recom- 
mended unconditionally. 

After  the  patient  has  been  anaesthetized  the  sphincters  should  be 
thoroughly  stretched.  By  this  means  whatever  fluid  or  fsecal  material  is 
retained  in  the  rectum  can  be  removed  and  the  organ  cleansed.  At  the 
same  time  any  ulceration  or  internal  fistulous  opening  can  be  seen, 
and  the  operation  will  thus  be  simplified.  It  is  important  that  the 
25 


386  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

stretching  should  be  done  before  scrubbing  the  outside  tissues,  because 
if  the  latter  is  done  first,  when  the  rectum  is  stretched  open  the  rectal 
contents  will  immediately  flow  out  over  the  external  parts  which  have 
been  scrubbed,  and  the  cleansing  will  have  been  in  vain.  After 
the  sphincters  have  been  dilated,  the  rectum  irrigated  with  a  1-to- 
2,000  bichloride  solution,  and  scrubbed  with  cotton  swabs,  a  good- 
sized  sponge,  threaded  on  a  strong  silk  ligature,  should  be  introduced 
to  prevent  the  escape  of  any  intestinal  contents  over  the  operative 
field. 

Having  thus  protected  the  lower  portion  of  the  rectum,  the  external 
surface,  the  buttocks,  the  perinffium,  and  the  scrotum  should  all  be 
thoroughly  scrubbed  with  soap,  bichloride  of  mercury,  and  alcohol. 
The  fistulous  tract  itself  should  be  injected  with  peroxide  of  hydro- 
gen or  a  solution  of  l-to-500  bichloride  of  mercury,  and  thorough- 
ly washed  out  in  order  to  free  it  as  far  as  possible  from  the  pyogenic 
germs. 

Position. — The  position  of  the  patient  for  operations  on  fistulas  de- 
pends largely  upon  the  habit  of  the  operator.     Some  prefer  the  lateral 

prone  position,  others  the  lithoto- 

^^    '^        ^^"^^  ^^y  position,  and  still  others  prefer 

I  '  J  to  have  the  patient  laid  upon  his 

\  m  chest  and  propped  up  in  the  knce- 

V  ■  chest    posture.       Practice     should 

I  B  vary  according  to  the  location  of 

^^^^  1  9<  the  fistula;  if  there  is  an  internal 

I^^^^MB  Jr^^HIl^.      opening  in  the  anterior  quadrant 

^^ga^l^^P^""    '      '    '^^1^^^^^     of  the  rectum,  it  is  best  to  have 

the  patient  in  the  extreme  prone 
position  with  the  thighs  drawn  well 
up  to  the  abdomen;  if  it  is  upon  the  side  or  posterior  quadrant 
the  lithotomy  position  is  preferable.  The  legs  will  be  held  in  posi- 
tion by  two  assistants,  or  better  still  by  the  Clover  crutch  (Fig.  130), 
or  Kelly's  straps.  The  upright  posts  upon  the  ordinary  gynaecological 
table  serve  fairly  well,  but  they  do  not  allow  of  as  much  separation  of 
the  thighs  as  the  apparatus  mentioned,  and  the  patient  is  likely  to  slip 
back  from  the  edge  of  the  table  when  these  are  used.  In  the  majority 
of  instances  one  may  say  that  the  lithotomy  position  is  the  more  satis- 
factory. 

Instruments. — The  instruments  necessary  for  an  operation  upon  fis- 
tula are  the  following: 

Proles. — These  should  be  of  various  sizes,  fiexible,  from  4  to  8  inches 
in  length,  and  have  flat  handles  in  order  to  determine  the  direction  of 
the  points  when  bent. 


Fig.  130. — Clover's  Crutch. 


FlSTtTLA 


387 


Fig.  131. 


-Beodie's  Probe-poesTed  Grooved 
Director. 


Grooved  Directors. — There  hare  been  a  niiniber  of  special  directors 
deyised  for  operations  upon  fistulas.  Some  are  made  -with  probe  points, 
as  that  of  Brodie  (Fig.  131).  Some  are  made  of  stiff  steel,  and  others 
of  flexible  material. 

AUingham  has  devised  one,  into  the  groove  of  which  a  sort  of  button 
attached  to  the  lower  blade  of  a  pair  of  strong  scissors  fits,  and  thus 
guides  it  as  the  tissues  are  cut  through.     These  instruments  are  in- 
genious, but  an  ordinary  steel 
or  German  silver  grooved  di- 
rector serves  eveiy  purpose. 

Knives. — The  operator 
should  be  provided  with  two 
curved  bistouries,  one  sharp  and  the  other  blunt-pointed,  a  good  scalpel, 
preferablj^  of  small  size,  and  one  with  a  long,  narrow  blade. 

Scissors. — These  should  be  straight,  angular,  and  curved  on  the  flat. 
The  Emmet  cervical  scissors  is  sometimes  very  useful,  but  not  indis- 
pensable. 

Artery  Forceps. — These  should  have  very  wide  jaws  and  small  points 
(Fig.  132)  in  order  that  the  ligatures  will  slip  over  them  easily,  as  it  is 
frequently  difiicult  to  tie  vessels  in  the  rectal  cavity  over  narrow-nosed 
forceps.  T-shaped  hsemostatic  forceps  (Fig.  133)  are  also  very  useful. 
One  should  also  have  two  or  more  long-blade  pressure  forceps  in  case 
it  is  necessary  to  grasp 
the  lips  of  the  wound 
en  masse. 

Tissue  Forceps.  — 
These  should  be  of  sev- 
eral varieties.  Plain 
dissecting,  mouse- 
tooth,  and  tissue  for- 
ceps with  wide  bite  are 
all  necessary  at  times. 
Some  of  these  should 
be  furnished  with  a 
fixation  clamp  in  or- 
der that  the  operator 
may  loosen  his  grip  at 
times. 

Needles. — These  should  be  round,  without  cutting  edges,  and  of  vari- 
ous curves  and  sizes.  Those  describing  a  semicircle  (Fig.  134)  are 
almost  indispensable  in  suturing  deep  fistulas. 

The  Needle-holder. — Without  assuming  to  make  comparisons,  in  a 
general  way  the  AVyeth  needle-holder  (Fig.  135)  is  by  all  means  the  most 


Fig.  133. — T-shaped  Hemostatic  Forceps. 


388  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

satisfactory  in  rectal  work.  It  inay  be  used  with  all  kinds  of  needles, 
and  has  one  great  advantage,  that  however  small  or  fine  the  needle 
grasped  may  be  it  is  not  broken. 

Suture  a7id  Ligature  Material. — Catgut,  both  plain  and  chromicized, 
silkworm  gut,  silk  thread,  kangaroo  tendon,  and  silver  wire  are  all  used 

at  times  for  fistula,  and  should  always  be 

\  S  in  one's  operating  bag. 

\^     ^     Jf  Specula     and     Retractors.  —  The     Van 

Buren  or  Sims's  duckbill  specula  are  the 

only  ones  which  are  of  any  particular  use 

in  operations  for  fistula.     Kectal  retractors 

are  also   quite  useful   in  connection   with 

_,„,-.,  „  these  instruments. 

Fig.   134. — Needles   for   Kectal 

Surgery  (Actual  Size).  Sharp  retractors  are  of  great  assistance 

to  hold  tlie  tissues  apart  when  one  attempts 
to  dissect  out  the  fistula  or  to  remove  the  cicatricial  tissues  at  its  base. 

Tenacula. — One  should  always  have  two  uterine  tenacula  in  oper- 
ating for  fistula,  as  they  are  frequently  of  great  assistance  in  accu- 
rately approximating  the  edges  of  the  wound  when  immediate  suture 
is  attempted. 

Cautery. — One  should  never  attempt  any  operation  on  the  rectum 
without  a  Paquelin  or  electro-cautery  at  hand.  The  former  is  much 
more  satisfactory,  and  they  are  now  made  so  compact  that  they  occupy 
little  space  in  the  operating-bag. 

After  all  these  preparations  the  surgeon  may  proceed  with  the  actual 
operation,  choosing  that  method  which  is  best  adapted  to  the  indi- 
vidual ease. 

Incision. — The  operation  of  incision  for  ano-rectal  fistula,  while  the 
simplest  is  by  no  means  the  oldest  of  the  procedures  in  this  disease. 
Excision,  crushing,  and  the  ligature  were  used  many  centuries  before 
Pott  first  advised  this 
simple  method.  It  is 
based  upon  the  one  idea 
of  overcoming  spasm  of 
the  sphincter,  which  by 
keeping  up  a  persistent  motion  in  the  parts,  acting  as  a  stricture  of  the 
rectum,  obstructing  the  free  discharge  of  gas  and  faecal  matters  through 
the  anus,  and  thus  forcing  them  out  through  the  fistula,  was  supposed 
to  prevent  its  healing. 

The  operation  in  complete  fistula  consists  in  the  thorough  division 
of  the  saeptum  between  the  rectum  and  the  fistulous  tract.  This  division 
may  be  carried  out  by  the  knife,  scissors,  thermo-cautery,  or  the  ecraseur. 
In  the  incomplete  type  it  consists  in  laying  open  the  fistulous  tracts 


Fig.  135. — Wyeth's  JSeedle-holdek. 


FISTULA 


389 


through,  the  skin  or  mucous  membrane  in  order  to  obtain  complete 
drainage  and  afford  opportunity  for  the  proper  cleansing  and  dressing 
of  the  parts.  Salmon  added  to  this  incisions  into  the  perifistulous, 
fibrous  tissue,  holding  that  they  hasten  the  development  of  healthy 
granulation.  Pott  in  his  original  brochure  upon  this  subject  advo- 
cated the  turning  of  incomplete  fistula  into  the  complete  variety  in 
order  to  overcome  the  mobility  occasioned  by  the  spasm  of  the  muscle. 
The  same  advantages  in  blind  external  fistula  may  be  obtained  by 
stretching  the  sphinc- 
ter without  the  expo- 
sure of  the  fistulous 
tract  to  the  infectious 
bacteria  in  the  intes- 
tine, and  -with  little 
danger  of  chronic  ul- 
ceration of  the  rec- 
tum and  incontinence 
of  iseces.  Wlierever  a 
fistulous  tract  of  this 
type  fails  to  heal  after 
this  treatment,  one  may 
set  it  down  as  a  fact 
that  the  patient  is 
either  syphilitic,  tuber- 
culous, or,  what  is  very 
much  more  likely  to 
be  the  case,  there  is  a 
communication  be- 
tween it  and  the  rec- 
tum which  the  operator  has  failed  to  discover.  It  may  be  said  that  it 
is  never  necessary  to  make  a  surgical  opening  in  the  rectum  for  the 
cure  of  a  fistula  where  no  pathological  opening  exists. 

The  steps  in  the  operation  are  as  follows: 

Blind  external  fistula  should  be  laid  open  by  a  circular  incision 
through  the  skin  parallel  with  but  outside  or  inside  of  the  external 
sphincter;  this  incision  should  be  wide  enough  to  drain  the  cavity  per- 
fectly and  leave  no  pockets.  In  the  complete  type  the  tract  should  be 
opened  little  by  little  outside  of  the  sphincter  until  a  point  immedi- 
ately below  the  internal  opening  is  reached;  then  with  a  grooved  director 
passed  through  this  and  out  of  the  anus,  the  overlying  tissues  should  be 
cut  in  a  perpendicular  direction,  thus  severing  the  fibers  of  the  sphincter 
squarely  across  (Figs.  136, 137).  If  there  are  any  connective-tissue  bands 
dividing  the  cavity  into  compartments,  these  should  be  broken  down  or 


Fig.  136. — Gkooved  Dieectoe  passed  theough  Fistulous 
Tract  ajjd  showing  how  passing  a  Bistouey  axojs'g  the 
Geoove  and  cutting  Outwaed  will  divide  the  Sphinc- 

TEE    ObLIQUELT. 


390 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


incised,  and  the  granulating  tissue  throughout  the  fistula  should  be 
scraped  away  with  a  curette  or  Volkmann's  spoon. 

Any  arteries  which  are  cut  should  be  ligated,  and  the  wound  packed 
firmly  enough  to  control  the  oozing  for  the  first  twenty-four  hours. 
After  this  the  dressing  should  be  just  sufficient  to  hold  the  lips  of  the 
wound  apart  and  secure  drainage.  The  firm  packing  of  these  wounds  is 
the  source  of  great  delay  in  their  healing.  The  parts  should  be  irrigated 
with  antiseptic  solutions  twice  a  day,  and  the  gauze  used  for  dressing 

soaked  in  a  10-per-cent 
mixture  of  ichthyol 
and  glycerin  or  5-per- 
cent balsam  of  Peru 
in  castor-oil. 

The  patient  should 
remain  in  bed  for  the 
first  week;  after  this 
time  he  may  begin  to 
go  about,  but  should 
not  be  allowed  to  as- 
sume the  sitting  pos- 
ture, inasmuch  as  pres- 
sure upon  the  parts 
produces  congestion 
and  delays  union.  In 
nearly  all  the  works 
upon  general  surgery 
it  is  advised  to  pass 
the  grooved  director 
through  the  tract  into  the  rectum,  if  possible,  and  if  not,  to  puncture 
the  rectal  wall  with  it  at  the  highest  point  of  the  fistulous  cavity, 
bringing  its  end  out  through  the  anus,  and  then  to  introduce  a  curved 
bistoury  along  the  groove  and  cut  the  tissues  from  within  outward. 
This  blind,  unscientific  procedure  may  result  in  a  cure  where  the 
director  passes  through  the  pathological  internal  opening  in  the  com- 
plete variety;  when  it  does  not  pass  through  this  opening  and  the 
wall  is  punctured,  it  is  almost  sure  to  result  in  failure,  because  a  part 
of  the  fistulous  tract  remains  untouched  (Fig.  128).  The  rest  of  the 
wound  may  be  perfectly  drained,  but  this  little  tract  continues  to  in- 
fect it,  and  will  eventually  prevent  complete  healing.  By  the  tech- 
nique described  above  one  knows  exactly  what  he  is  cutting;  the 
rectum  is  laid  open  only  from  the  internal  aperture  outward,  and 
the  muscles  are  cut  at  the  angle  most  favorable  for  the  restoration  of 
function. 


Fig.   137. — Fistula   laid   open   Outside   of    Sphincter   so 

THAT   THE    LaTTER    CAN    BE    CUT    SqUARELY    AcROSS. 


FISTULA  391 

If  the  internal  opening  is  above  both  sphincters,  it  is  better  to  excise 
as  much  of  the  upper  portion  of  the  tract  as  possible  and  suture  it 
together  with  the  internal  sphincter  than  to  attempt  the  operation  by 
open  incision.  Even  if  the  complete  fistula  can  not  be  dissected  out 
and  sutured,  this  upper  portion  -null  very  likely  unite  if  the  drainage 
below  is  perfect,  and  thus  the  function  of  the  muscle  will  be  retained. 
If  there  are  large,  hard  masses  of  cicatricial  tissue  surrounding  the 
fistula,  they  should  be  dissected  away  as  completely  as  possible,  provided 
one  has  thoroughly  eliminated  tuberculosis  from  the  case.  If,  however, 
the  fistula  is  of  tubercular  nature,  and  it  is  deemed  wise  to  operate 
by  the  open  method,  the  Paquelin  cautery  should  be  employed  instead 
of  the  knife  for  all  incisions,  and  the  entire  tract  be  burned  instead  of 
curetted.  The  so-called  Salmon  back-cut  into  the  cicatricial  tissue  is 
not  to  be  compared  for  a  moment  with  actually  dissecting  out  the  cica- 
tricial tissue. 

Excisiox  OF  Fistula. — The  treatment  of  fistula  by  excision  is  very 
old.  Long  before  the  publication  of  Pott's  classical  paper  in  ITTQ,  phy- 
sicians had  practised  cutting  out  the  fistulous  tract,  and  with  more  or 
less  success.  Owing  to  the  fact  that  so  much  tissue  was  removed  and 
no  regard  paid  to  the  preservation  of  the  sphincter  muscle,  the  results 
were  often  disastrous  so  far  as  continence  was  concerned,  and  profuse 
hemorrhages  frequently  occurred  through  the  imperfect  methods  of 
hgemostasis  at  that  period.  Cheselden's  method  of  introducing  a  poly- 
pus forceps  into  the  fistulous  tract  and  cutting  out  all  the  tissue  em- 
braced by  the  blades  was  barbarous,  and  need  not  be  discussed  at  the 
present  time.  The  operation  of  excision  has  its  merits  in  that  it  aims 
at  the  absolute  eradication  of  all  diseased  tissue,  and  where  the  dissec- 
tion is  so  carefully  conducted  as  to  avoid  too  great  destruction  of  the 
sphincter  it  will  produce  excellent  results.  In  old  cases  with  large 
cicatricial  deposits  it  is  advisable,  even  if  the  resulting  wound  can  not 
be  accurately  brought  together  by  sutures.  The  writer  has  succeeded 
in  curing  by  this  method  a  number  of  such  cases  in  which  simj)le  in- 
cision had  utterly  failed. 

Excisiox  with  Immediate  Sutuee. — This  operation,  originally  con- 
templated for  the  treatment  of  small  direct  fistulas,  is  being  more  and 
more  applied  to  those  of  larger  dimensions.  It  was  originally  introduced 
by  Chassaignac,  who  records  a  case  in  which  he  applied  it  in  1856  (Traite 
de  I'ecrasement  lineaire,  1856,  p.  168).  He  does  not  state  how  many 
times  he  attempted  the  operation,  but  it  failed  owing  to  infection  and 
suppuration  of  the  wound.  Xo  further  attempts  were  made  in  this 
direction  until  18T9,  when  Stephen  Smith,  of  Bellevue  Hospital,  follow- 
ing the  imperfect  antiseptic  technique  of  that  day,  undertook  the  treat- 
ment of  a  number  of  fistulas  by  radical  excision  and  immediate  suture. 


392 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


While  Smith's  method  of  excision  and  introduction  of  sutures  is  prac- 
tically the  same  as  that  laid  down  by  Chassaignac,  it  is  entirely  due  to 
him  that  iinpetus  has  been  given  to  the  present  method  of  operation, 
and  the  recognized  technique  of  its  performance  has  been  prescribed. 

The  preparation  of  the  patient  by  purges,  enemas,  shaving,  etc.,  must 
be  carefully  carried  out.     It  is  important  also  that  the  fistulous  tract 


Fig.  138. — First  Step  in  Excision  of  Fistula. 


should  be  treated  with  peroxide  of  hydrogen  and  antiseptic  solutions  for 
several  days  before  the  contemplated  operation.  After  the  patient  is 
anaesthetized  he  should  be  placed  in  Avhatever  position  affords  the  opera- 
tor the  easiest  access  to  the  parts. 

The  sphincters  should  be  stretched  and  the  parts  cleaned  according 
to  the  directions  already  given.  The  succeeding  steps  of  the  operation 
will  depend  upon  whether  the  fistulous  tract  is  a  simple,  straight  canal 
or  a  tortuous,  irregular,  abscess  cavity. 

In  the  first  instance  the  probe  or  grooved  director  should  be  intro- 
duced through  the  fistulous  tract;  preferably  a  pure  silver  probe  long 
enough  to  be  bent  and  held  as  a  sort  of  traction  loop  (Fig.  138).  The 
skin  and  mucous  membrane  covering  the  fistulous  tract  should  then  be 
incised  in  a  straight  line  from  the  external  to  the  internal  opening  and 
dissected  back  a  little  to  each  side;  the  deeper  tissue  should  then  be 


FISTULA 


393 


incised  until  one  comes  upon  the  cicatricial  or  indurated  wall  of  the 
fistulous  tract;  if  this  tract  passes  outside  of  the  external  sphincter  or 
through  its  fibers^  it  will  be  perfectly  feasible  to  cut  these  fibers  trans- 
versely and  draw  them  to  one  side  so  that  none  of  their  substance  will 
be  removed. 

Having  thus  cut  down  upon  the  fistulous  tract,  but  not  into  it,  the 
incision  is  carried  around  the  external  opening,  and  the  entire  indurated 
mass  dissected  upward  and  inward  until  it  is  completely  removed  by  a 
circular  incision  around  the  internal  opening  (Fig.  139).  In  this  man- 
ner the  fistula  is  excised  in  toto,  and  remains  threaded  upon  the  probe. 
One  must  be  familiar  with  the  appearance  of  the  diseased  tissues  in 
such  cases,  and  be  very  careful  to  go  entirely  outside  of  them  in  the 
dissection.     When  during  such  an  oj)eration  the  diseased  tissue  is  in- 


FiG.  139. — Removal  of  a  Fistula  thbeaded  upon  a  Peobe. 

(In  the  case  from  which  this  illustration  was  drawn  the  dissection  was  made  from  within 
outward,  but  ordinarily  this  course  should  be  reversed.) 


vaded  by  the  scissors  or  knife,  the  instrument  should  be  changed  for 
another  lest  by  any  possibility  the  healthy  tissues  should  be  infected. 

Having  removed  the  tract,  the  application  of  the  sutures  is  the  next 
step.  Considerable  ingenuity  will  need  to  be  exercised  in  every  case 
to  bring  the  parts  accurately  together.    The  first  step  consists  in  intro- 


394: 


THE  ANUS,  RECTUM,   AND   PELVIC  COLON 


ducing  two  or  throe  silk^yorm-gut  sutures  from  one  side  of  the  wound 
to  the  other  and  entirely  below  it;  these  are  intended  to  prevent  traction 
on  the  deeper  sutures,  and  their  ends  are  left  loose  until  the  latter  are 
all  in  place.  After  this  the  deeper  portions  of  the  wound  are  brought 
together  b}^  a  continuous  suture  of  medium-sized  catgut.  Plain  steril- 
ized gut  is  better  for  this  purpose  than  the  chromicized.  As  the  tissues 
through  which  these  sutures  pass  are  frequently  of  a  fragile,  cellular 
nature,  the  mattress-stitch  will  be  found  most  satisfactory  (Fig.  140). 
Layer  by  layer  the  parts  are  brought  together  until  the  wound  is  closed 
to  the  level  of  the  skin  or  mucous  membrane.  The  divided  ends  of  the 
sphincter  are  brought  together  by  interrupted  sutures.  The  deep  suture 
is  not  used  to  bring  the  skin  and  mucous  membrane  together.  The 
reason  for  this  is  that  it  is  almost  impossible  to  sterilize  the  skin,  and 
hence  if  the  same  suture  which  is  used  in  the  deeper  tissues  be  passed 
through  it,  infection  is  liable  to  follow  its  tract  downward  into  the 


deeper  portions  of  the  Avound.  Subcutaneous  suturing  of  the  edges  of 
the  wound  has  resulted  unsatisfactorily.  The  very  slightest  puncture 
which  will  hold  the  edges  in  apposition  should  be  made  in  order  that 
the  needle  and  thread  may  not  penetrate  into  the  cellular  tissues  and 
thus  possibly  infect  them.    By  these  means  the  entire  tract  is  accurately 


FISTULA  395 

brought  together  and  closed  (Fig.  141).  After  this  has  been  accom- 
plished, the  deep  anchoring  or  reenforcing  sutures  first  introduced  are 
tied  together,  thus  supporting  the  deeper  ones  and  bringing  the  parts 
into  closer  apposition.  All  bleeding  and  oozing  should  be  thoroughly- 
checked  before  the  suturing  begins.     After  the  wound  has  been  accu- 


FiG.  141. — FixAL  Step  in  closing  Fistula. 

rately  closed,  it  should  be  sealed  with  iodoformized  collodion  and  thus 
be  protected  from  the  fsecal  discharges  which  may  escape  after  the 
operation. 

Another  method  is  to  suture  the  edges  of  the  skin  wound  up  to  the 
margin  of  the  anus;  the  slit  in  the  mucous  membrane  is  then  rounded 
off,  and  that  above  its  upper  angle  is  loosened  up  from  the  tissues,  Just 
as  in  the  Whitehead  operation  for  hemorrhoids,  and  is  then  dragged 
down  and  sutured  to  the  surface  skin  a  slight  distance  beyond  the 
margin  of  the  anus.  The  idea  of  this  consists  in  producing  an  abso- 
lutely impervious  layer  covering  that  portion  of  the  wound  inside  the 
anus  or  rectum,  so  that  there  will  be  no  possibility  of  faecal  percolation 
into  the  wound.  Whatever  discharges  occur  will  pass  over  this  valve- 
like flap  of  mucous  membrane  in  which  there  is  no  solution  of  continuity, 
and  will  thus  be  discharged  outside  without  coming  into  contact  with 
the  edges  of  the  wound.     The  external  skin  surface  being  then  protected 


396  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

by  collodion  and  proper  dressing  will  run  little  risk  of  becoming  in- 
fected (Fig.  l-i2). 

After  the  operation  lias  been  thus  completed,  antiseptic  gauze  is  laid 
over  the  wound  and  held  in  position  with  a  flat  retractor,  so  that  it 
will  be  impossible  for  the  sponge  in  the  rectum,  which  should  be. with- 
drawn, to  come  in  contact  with  the  edges  of  the  wound  during  with- 
drawal. After  this,  with  the  retractor  held  in  position  and  a  Sims's 
vaginal  speculum  upon  the  opposite  side  of  the  rectum,  a  medium-sized 
drainage-tube,  wrapped  with  a  small  quantity  of  gauze  and  covered 
with  rubber  protective,  is  introduced  about  3  inches  into  the  rectum 


•I ■■ 

/ 

1                   1 

!          \ 

1 

Fig.  142. — Eectal  Portion  of  Fistula  closed  by  Flap  of  Mucous  Membrane. 

and  allowed  to  remain  for  several  days  in  order  to  facilitate  the  escape 
of  gas  and  any  fluid  fsBces  which  may  come  down  from  the  intestine 
above. 

The  after-treatment  consists  in  confining  the  patient  absolutely  to 
bed,  controlling  the  bowels  by  a  certain  quantity  of  opiates  for  six  or 
seven  days,  and  limiting  him  to  liquid  albumenoid  diet.  A  milk  diet 
is  not  satisfactory  in  such  cases  owing  to  the  hard,  caseous,  insoluble 
stools  produced  by  it.  At  the  end  of  six  or  seven  days  the  patient's 
bowels  are  moved  by  the  injection  of  5  ounces  of  warm  water  and  1 
ounce  of  glycerin,  in  which  is  dissolved  2  ounces  of  inspissated  ox-gall. 


FISTULA  B9T 

This  proceeding  may  have  to  be  repeated  several  times  before  an  efficient 
evacuation  is  obtained,  but  it  is  not  advisable  to  attempt  the  use  of 
any  laxative  or  purgative  until  the  lower  bowels  have  been  relieved  of 
any  accumulation  of  hardened  faecal  masses  such  as  are  likely  to  follow 
the  administration  of  opium  and  prolonged  constipation.  After  these 
masses  have  been  dissolved  by  the  ox-gall  and  glycerin,  one  may  then 
administer  some  mild  laxative,  and  induce  regular  daily  movements. 

Eest  in  bed  is  incumbent  upon  these  patients  for  at  least  two  weeks 
in  order  to  secure  firm  and  perfect  healing  of  the  parts,  at  which  time, 
if  primary  union  shall  have  taken  place,  the  fistula  will  be  cured.  The 
little  mucous  flap  does  not  unite  to  the  skin  surface  to  which  it  is  sewed, 
but  does  unite  to  the  raw  surface  down  to  the  margin  of  the  skin.  After 
the  stitches  are  removed  that  portion  of  it  which  extends  beyond  the 
margin  of  the  skin  will  retract  and  entirely  disappear. 

In  tortuous  fistulas  with  large  abscess  cavities  and  burrowing  tracts 
the  operation  is  more  difficult.  In  such  cases  the  fistula  should  first  be 
flooded  with  95-per-cent  carbolic  acid  and  then  with  a  solution  of 
methylene  blue  in  alcohol.  The  alcohol  neutralizes  the  acid  and  the 
methylene  blue  stains  the  fistulous  tract  and  sinuses  so  that  they  can  be 
easily  followed  in  the  dissection.  The  skin  overlying  the  fistulous  tract 
should  then  be  incised;  the  sphincter  muscle  cut  squarely  across  and  its 
ends  pulled  aside,  so  that  they  can  be  accurately  reunited;  then  the 
fistula  with  all  its  diverticula  and  surrounding  cicatricial  tissue  should 
be  carefully  dissected  out;  and  finally  all  bleeding  vessels  and  oozing 
should  be  controlled  before  beginning  to  close  the  wound.  Having 
accomplished  this,  the  deep  sutures  should  be  introduced  as  described  on 
page  394.  It  may  sometimes  be  advisable  to  pass  one  of  these  sutures 
around  the  wound  in  a  horizontal  direction  after  the  manner  of  a  purse- 
string.  The  deeper  parts  of  the  wound  are  then  brought  together  layer 
by  layer  with  continuous  or  interrupted  sutures,  according  to  which 
produces  the  most  accurate  apposition.  As  Smith  states,  there  is  scarcely 
any  fistula  which  can  not  be  completely  and  thoroughly  closed  by  this 
method  of  suturing.  The  superficial  layers,  the  ends  of  the  sphincter 
muscle,  and  the  skin  are  brought  together  in  the  manner  already 
described.  As  yet  the  author  has  not  had  the  opportunity  to  use  the 
mucous  flap  in  any  extensive  operation  for  excision  and  suture  of  ano- 
rectal fistula,  but  there  is  no  reason  why  it  should  not  be  applicable  to  all 
types,  and  a  means  of  great  protection  against  infection  by  discharges 
from  the  intestinal  canal. 

After  the  closure  of  the  wound,  the  deep  purse-string  or  reenforcing 
suture  should  be  tied  as  previously  described,  the  sponge  withdrawn, 
and  the  parts  dressed  in  the  same  manner  as  in  the  simple  variety. 

It  is  wise  in  cases  of  large  dissection  and  suture  to  strap  the  folds 


898  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

of  the  buttocks  together  with  wide  adhesive  straps,  and  to  bind  the 
knees  together  with  a  bandage  or  towel  in  order  tliat  the  movements 
of  the  patient  in  bed  may  not  cause  traction  upon  the  wound  and  thus 
break  loose  the  sutures. 

By  this  method  the  absolute  removal  of  the  diseased  tissues  is  accom- 
plished, the  accurate  apposition  of  the  parts  insures  better  functional 
results,  and  finally  a  great  deal  of  time  and  exhaustion,  which  neces- 
sarily follows  the  long  processes  of  healing  by  granulation  and  suppura- 
tion, are  saved. 

The  argument  used  against  it  is  that  primary  union  may  fail,  and 
does  fail  in  a  number  of  cases.  This  is  not  a  valid  objection,  for  the 
simple  reason  that  where  the  union  does  fail,  absolutely  nothing  is  lost; 
one  has  accomplished  ever)H;hing  that  is  intended  by  the  open  opera- 
tion, and  the  patient  proceeds  to  recovery  by  the  same  process  of 
granulation  which  would  have  been  necessary  if  no  suturing  had  been 
done.  If  the  operator  is  careful  in  his  after  attention  there  is  abso- 
lutely no  danger  of  fresh  abscess  and  burrowing  taking  place.  The 
S}anptoms  of  such  conditions  are  perfectly  clear,  and  if  one  should  form 
it  can  be  opened  externally  and  drained,  and  the  parts  still  heal  in  less 
time  than  the}^  would  by  the  method  of  incision. 

This  method  is  inapplicable  to  those  cases  in  which  the  fistula  is  com- 
plicated by  long,  tortuous  tracts  that  extend  up  into  the  superior  pelvi- 
rectal or  retro-rectal  spaces,  but  in  any  case  in  whicli  the  depth  of  the 
fistula  does  not  exceed  2^  inches  excision  and  suturing  may  be  accurately 
carried  out  by  a  skilful  operator. 

In  the  application  of  these  principles  to  the  different  varieties  of 
fistula,  the  chief  difficulty  is  to  distinguish  between  the  anatomical  and 
pathological  types  of  the  disease.  Where  the  diagnosis  is  accurate,  one 
can  not  make  any  mistake  in  the  selection  of  the  method  to  be  em- 
ployed. The  large  majority  of  failures  which  follow  operations  for 
fistula  are  due  to  one  of  two  facts:  either  a  specific  fistula  is  mistaken 
for  a  simple  one,  or  the  pathological  opening  into  the  rectum  is  not 
found,  and  thus  a  part  of  the  tract  remains.  If  these  errors  are  avoided, 
every  operation  for  non-specific  fistula  ought  to  prove  successful. 

In  blind  internal  fistula  the  technique  varies  slightly. 

In  simple  subtegumentary  cases  in  which  the  opening  can  be  found 
and  a  probe  bent  upon  itself  introduced  into  it,  a  small  counter  puncture 
may  be  made  upon  the  lower  end  of  the  probe  and  the  intervening  tis- 
sues can  then  be  incised  by  scissors  or  the  cautery,  or  it  can  be  excised 
and  sutured.  If  the  fistula  has  burrowed  outside  of  the  muscles  into 
the  ischio-rectal  fossa  and  beneath  the  skin,  incision  through  tliis  tegu- 
ment will  convert  it  into  the  complete  variety,  and  it  should  then  be 
treated  as  such.     Where  such  a  conversion  can  be  made  without  tlie  use 


FISTULA 


399 


of  general  angesthesia  it  is  always  well  to  do  this,  and  try  drainage  and 
stimulating  applications  for  a  week  or  two  before  resorting  to  radical 
operation.  This  conservatism  is  especially  important  where  the  open- 
ing is  above  the  internal  sphincter  and  its  tract  passes  outside  of  this 
muscle. 

Sometimes  the  fistulous  tract  does  not  run  downward,  but  runs  up- 
ward underneath  the  mucous  membrane  of  the  rectum.  In  such  cases 
the  upper  portion  of  the  tract  may  extend  beyond  the  reach  of  the  finger, 
and  the  incision  may  possi- 
bly be  followed  by  severe 
haemorrhage.  In  such  cases 
one  blade  of  a  long,  nar- 
row pressure  forceps  may 
be  introduced  into  the  tract 
while  the  other  passes  into 
the  cavity  of  the  rectum; 
they  are  closed  and  al- 
lowed to  remain  until  the 
tissues  are  cut  through. 
If  the  entire  tract  is  not 
laid  open  at  the  first  at- 
tempt, the  forceps  may  be 
introduced  a  little  higher 
at  a  second  sitting. 

Where  the  tract  leads 
downward  in  a  tortuous 
direction,  and  the  probe 
can  not  be  passed  from 
within,  it  is  sometimes  pos- 
sible by  bimanual  palpation 
to  discover  the  induration 
in  the  perineal  region,  and 
to  cut  down  upon  it  from  the  outside  and  thus  convert  it  into  a  com- 
plete fistula. 

Sometimes  these  fistulas  bifurcate  and  form  Y-shaped  tracts  (Fig. 
143).  When  this  is  the  case,  laying  open  one  of  the  branches  will  not 
be  followed  by  healing,  but  suppuration  will  continue.  In  operating 
one  should  be  very  careful  to  search  each  side  of  the  wound  for  any 
such  diverging  tracts,  and  if  found  lay  them  open  at  once. 

The  methods  of  treating  these  blind  internal  fistulas  by  injections 
of  stimulating  fiuids  without  laying  them  open  are  utterly  unreliable. 
The  cavities  are  constantly  reinfected  by  the  intestinal  contents,  and 
without  complete  drainage  and  antiseptic  treatment  one  can  not  expect 


Fig.  143. — Y-shaped  Blind  Internal  Fistula. 


400 


THE  ANIJS,   RECTUM,  AND   PELVIC   COLON 


them  to  heal.  After  the  tracts  have  been  laid  open  the  sphincters 
should  be  thoroughly  dilated  and  the  treatment  for  simple  rectal  ulcera- 
tion begun.     In  these  cases  rest  in  bed  is  imperative,  the  diet  should 

be  carefully  regulated,  and 
the  stools  kept  regular  and 
semisolid. 

No  force  should  ever  be 
used  in  the  introduction 
of  a  probe  or  grooved  di- 
rector into  a  fistulous  tract. 
The  cellular  tissues  about 
the  parts  are  so  soft  that 
they  may  be  easily  pene- 
trated, and  one  may  even 
incise  both  the  external 
and  internal  openings  and 
yet  leave  a  part  of  the  fis- 
tula intact  (Fig.  144). 

After  the  fistulous  tract 
has  been  laid  open,  it  often 
happens  that  the  burrow- 
ing around  the  rectum  ex- 
tends considerably  above 
the  level  of  the  internal 
opening.  j\Iany  operators 
claim  that  it  is  wise  to  incise  the  rectal  wall  up  to  the  highest  point 
of  such  cavities.  This,  however,  is  rarely  necessary.  If  the  parts  are 
thoroughly  drained  and  the  sphincters  put  at  rest  by  stretching  and 
incision,  these  cavities  will  rapidly  fill  up  by  healthy  granulation,  and 
the  cutting  of  the  internal  sphincter  will  be  avoided.  If,  however,  there 
should  be  a  burrowing  tract  involving  only  the  mucous  membrane  of 
the  rectum,  it  is  safer  to  lay  this  open.  In  order  to  avoid  ha?morrhage, 
the  heated  knife  should  be  used  for  this  purpose.  All  burrowing  tracts 
and  diverticuli  should  be  freely  laid  open  into  the  main  wound.  Where 
the  fistula  is  connected  by  burrowing  tracts  with  the  retro-rectal  or 
pelvi-rectal  spaces,  these  cavities  should  be  opened  into  the  general 
wound  and  drained  by  the  introduction  of  rubber  tubes. 

The  dressing  of  the  wounds  after  all  these  operations  for  fistula  is 
the  same  as  that  already  described;  they  should  never  be  packed  tightly, 
inasmuch  as  this  holds  the  tissues  apart  and  results  in  delayed  union 
with  extensive  cicatrices. 

Complex  Fistula.— Quite  a  large  percentage  of  fistulas  are  of  the 
complex  variety.    Any  perirectal  abscess  or  fistula,  if  improperly  drained. 


Fig.  144. — Dieectob  PAssrNG  through  Internal  and 
External  Openings  or  Fistula  and  leaving  Part 
OF  Tract  Untouched. 


FISTULA 


401 


may  resolve  itself  into  this  variety  through  burrowing  and  destruction 
of  tissue. 

They  are  described  as  fistulas  with  lateral  burrowing  tracts,  watering- 
pot  fistulas,  and  horseshoe  fistulas. 

Fistula  with  Lateral  Burrowing  Tracts. — Any  simple  fistula  resulting 
from  an  abscess  left  to  open  spontaneously,  or  occurring  in  individuals 
with  vitiated  constitutional  conditions,  is  likely  to  become  complex 
by  burrowing  tracts  leading  off  from  the  abscess  cavity.  Goodsall 
pointed  out  many  years  ago  the  rules  of  extension  of  fistulous  tracts. 
Those  in  the  anterior  quadrant  proceed  directly  into  the  anus  or  rectum, 
the  aperture  being  found  almost  perpendicularly  above  the  external 
opening.  Those  in  the  posterior  quadrants  extend  circularly  around  the 
anus,  and  generally  open  at  some  j^oint  near  the  posterior  commissure. 

Subtegumentary  fistulas  at  any  point  on  the  anal  circumference  may 
burrow  subcutaneously  in  all  directions,  because  there  are  no  connec- 
tive-tissue walls  to  obstruct  them.  Those  situated  anteriorly  are  likely 
to  extend  forward  into  the  perineum  and  scrotum  or  upward  into  the 
cruro-scrotal  fold.  Those 
situated  posteriorly  bur- 
row outward  into  the  but- 
tocks, or  upward  behind 
the  coccyx  and  sacrum  be- 
neath the  skin.  The  ex- 
tent to  which  these  sub- 
cutaneous burrowings  may 
take  place  is  very  remark- 
able. In  one  case  a  small 
anterior  fistula  burrowed 
forward  through  the  peri- 
neum and  crural  folds  and 
upward  into  the  iliac  re- 
gion, opening  upon  the 
skin  at  a  point  near  the 
anterior  superior  spine  of 
the  ilium.  In  another  case 
(Fig.  147)  a  superficial  fis- 
tula burrowed  upward  out- 
side of  the  sacrum  and  coccyx,  turned  anteriorly  above  the  level  of 
the  fourth  sacral  vertebra,  passed  underneath  the  gluteal  muscles,  and 
opened  at  a  point  Just  below  the  greater  trochanter. 

An  apparently  simple,  direct,  subtegumentary  fistula  may  have  a 
tract  burrowing  upward  into  the  ischio-rectal  fossa  (Fig.  145)  or  even 
entering  the  superior  pelvi-rectal  space.     Submuscular  fistulas  passing 
26 


Fig.  145. — Fistulous  Teact  passino  through  Exter- 
nal Sphincter. 


402 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


through  the  ischio-rectal  fossa  are  very  liable  to  have  burrowing  sinuses 
leading  off  from  them  into  the  fossa  of  the  opposite  side,  or  into  the 
retro-rectal  space  (Fig.  146).  Where  they  extend  around  the  anterior 
or  posterior  connuissure  of  the  anus  they  are  called  horseshoe  fistulas. 
It  has  frequently  happened  tliat  small  subcutaneous  fistulas,  after 
having  been  laid  open,  continue  to  suppurate  for  long  periods,  and  upon 
close  examination  in  these  cases  it  has  been  discovered  that  small  sub- 
mucous tracts  were  burrowing  upward  beyond  the  internal  opening  of 
the  fistula. 

The  treatment  of  these  varieties  of  complex  fistula  has  been  prac- 
tically described  under  those  of  general  operations.  It  consists  in 
the  incision  and  thorough  drainage  of  every  burrowing  tract,  whether 
it  be  superficial  or  deep.  In  the  superficial  variety  excision  and  imme- 
diate suture  may  be  applied.     Where  simple  incision  is  employed  the 

cutting  should  always  be 
made  beyond  the  limit  of 
the  burrowing  of  the  tract 
for  the  reason  that  the 
edges  of  the  skin  rapidly 
retract  and  may  very  easily 
form  a  pocket  before  heal- 
ing from  the  bottom  has 
taken  place.  It  is  neces- 
sary to  say  something  upon 
the  treatment  of  fistulas 
opening  at  remote  dis- 
tances from  the  anus.  In 
certain  of  these  cases  the 
large  amount  of  tissue  in- 
volved and  the  extent  of 
the  wound  necessary  to  lay 
open  the  entire  tract  cre- 
ates a  condition  entirely 
out  of  proportion  to  the 
gravity  of  the  disease.  In 
the  case  opening  near  the 
trochanter  (Fig.  147)  the 
laying  open  of  the  fistulous 
tract  would  have  involved  the  cutting  of  the  gluteus  maximus  and 
medius,  the  gluteal  artery  and  lesser  sciatic  nerve,  together  with  a  wound 
of  no  less  than  18  inches  in  length.  In  such  cases  it  is  advisable  to 
follow  the  fistulous  tract  from  the  external  opening  as  far  as  possible 
with  a  long  probe,  and  at  that  place  make  a  counter  opening  large  enough 


Fig.  146. — Subtegumentary  Fistula  involving  Ischio- 
rectal AND  Ketko-rectal  Spaces. 


FISTULA 


403 


to  admit  a  drainage-tube  into  it.  From  this  incision  the  probe  can 
then  be  introduced  still  farther  and  a  second  counter  o^oening  made 
as  before^  and  so  on  until 


one  is  made  at  a  site  about 
1  or  2  inches  from  the  anal 
margin.  From  this  point 
to  the  internal  opening  of 
the  fistula  all  the  overlying 
tissues  may  be  cut  through, 
and  the  condition  treated 
as  one  of  complete  fistula 
extending  from  the  last 
counter-opening.  The  fis- 
tulous tract  beyond  this 
last  counter-opening  is 
treated  by  curetting,  stimu- 
lating applications,  and 
drainage.  As  a  rule  they 
will  close  rapidly  and  com- 
pletely. Of  course  if  there 
should  be  lateral  burrow- 


FiG.  147. — LoxG^  Fistulous  Tract  opexisg  >-eae  the 
Greater  Trochanter. 


ing  tracts  from  this  main  fistulous  canal,  it  would  be  necessary  to  lay 
these  open  and  drain  as  has  been  previously  described. 

Fistula  icWi  more  than  One  External  Opening :  Watering-pot  Fistula. — 
When  a  fistula  has  existed  for  an  indefinite  length  of  time  and  the  drain- 
age has  been  insufficient,  numerous  burrowing  tracts  ma}'  form  and 
each  open  externally  upon  the  skin.  In  this  manner  there  will  be  estab- 
lished what  has  been  described  as  watering-pot  fistula.  The  number  of 
such  external  openings  is  unlimited.  Goodsall  and  ]\Iiles  have  described 
a  case  in  which  there  were  forty-three  separate  and  distinct  external 
apertures.  This  by  no  means  implies  a  multiplicity  of  internal  openings, 
for  in  the  majority  of  these  cases  there  is  only  one. 

The  number  of  external  openings,  however,  does  bear  some  relation 
to  the  size  of  the  internal  opening,  to  the  constitutional  condition  of  the 
patient,  and  the  duration  of  the  fistula  (Goodsall  and  Miles,  p.  IIT). 
Ordinarily  in  cases  with  numerous  external  openings  one  will  find  a 
large  internal  opening,  generally  between  the  two  sphincters,  and  into 
which  the  ends  of  one  or  two  fingers  can  be  introduced.  Sometimes  a 
soft,  flexible  probe  introduced  through  this  internal  opening  will  pass 
directly  out  through  the  primary  external  opening,  and  where  there  is 
any  doubt  in  the  mind  of  the  patient  as  to  which  of  these  occurred  firsts 
this  may  prove  a  practical  solution  of  the  problem. 

The  treatment  of  this  condition  will  depend  largely  upon  the  consti- 


404  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

tutional  condition  of  tlie  patient.  As  a  rule  it  would  be  well  to  k}-  open 
all  the  fistulous  tracts  into  one  large  cavity,  preserving  as  far  as  possible 
the  islets  and  tongues  of  skin  in  order  to  facilitate  the  cicatrization  and 
healing  of  the  parts;  but  such  patients  are  apt  to  be  much  debilitated 
and  weakened  by  the  excessive  discharges,  and  extensive  operations  are 
therefore  unadvisable.  If  it  is  possible  to  follow  the  tract  from  the 
internal  to  the  primitive  external  opening,  it  is  better  to  lay  this  open, 
curette  and  cauterize  the  same,  and  trust  to  the  drainage  thus  obtained 
to  heal  the  other  openings  and  the  sinuses  leading  to  them.  In  case  that 
does  not  succeed,  the  patient's  condition  will  in  the  meantime  be  im- 
proved by  constitutional  treatment  and  the  checking  of  septic  absorp- 
tion, and  he  will  be  in  a  better  condition  to  tolerate  incision  of  all  the 
collateral  tracts. 

Excision  and  suture  are  impracticable  in  cases  of  this  kind.  ]\Ian)^ 
of  those  which  the  author  has  seen  have  been  associated  with  constitu- 
tional syphilis,  and,  while  not  being  complicated  by  any  syphilitic 
stricture  of  the  rectum,  they  have  proved  obstinate  to  treatment 
until  the  effects  of  mercury  and  iodide  of  potash  have  been  well 
established. 

Fistula  luith  more  than  One  Internal  Opening. — This  variety  is  much 
more  rare  than  the  preceding.  There  may  exist  two  internal  openings 
connected  with  two  distinct  fistulas,  or  there  may  be  two  or  more  con- 
nected with  only  one  external  opening.  It  may  be  caused  through  punc- 
ture of  the  rectal  walls  by  a  sharp  bone,  needle,  or  other  foreign  body 
caught  crosswise  in  the  rectum  and  setting  up  two  distinct  abscesses  and 
fistulous  tracts  upon  opposite  sides.  These  abscesses  may  burrow,  coa- 
lesce outside  of  the  rectum,  and  open  by  one  common  external  aperture. 
It  sometimes  happens  also  that  in  a  horseshoe  fistula  or  double  abscess 
of  the  ischio-rectal  fossae,  an  opening  may  occur  within  the  rectum  on 
each  side,  whereas  only  one  exists  externally. 

The  treatment  of  this  variety  depends  entirely  upon  the  anatomical 
character  of  the  fistulas;  if  they  are  subtegumentary  they  should  be  laid 
freely  open  or  dissected  out  and  the  wound  sutured;  if,  however,  the 
tract  is  submuscular  it  would  be  unwise  to  attempt  an  operation  by  incis- 
ing both  tracts  at  the  same  time.  It  is  better  to  lay  open  one  tract 
thoroughlj'  through  the  sphincter  muscle,  extend  the  incision  laterally 
so  as  to  establish  complete  drainage,  and  at  the  same  time  cauterize  the 
other  openings  and  tracts  with  a  saturated  solution  of  nitrate  of  silver. 
If  necessary  secondary  operations  may  be  performed  after  the  first  has 
healed,  and  ordinarily  the  remaining  fistula  will  be  so  reduced  that  ex- 
cision with  immediate  suture  can  then  be  performed  with  safety. 

Horseshoe  Fistula. — This  consists  in  a  fistulous  tract  surrounding  the 
posterior  or  anterior  commissure  of  the  rectum.     Occasionally  one  finds 


FISTULA 


4.05 


both  conditions  in  the  same  patient,  the  fistula  tlius  forming  a  complete 
circuit  of  the  rectum  (Fig.  148). 

The  typical  horseshoe  fistula  consists  in  a  tract  that  runs  from  one 
ischio-rectal  fossa  above  the  aponeurosis  of  the  external  sphincter  and 
around  the  posterior  commissure  of  the  rectum  into  the  fossa  of  the 
opposite  side.  It  may  have  one  or  two  external  openings;  it  may  have 
one,  two,  or  no  inter- 
nal openings;  as  a  rule 
there  is  one  external 
opening  upon  one  side 
or  the  other  of  the 
anus,  and  one  internal, 
usually  at  the  posterior 
commissure  of  the  rec- 
tum just  above  the 
margin  of  the  external 
sphincter. 

It  is  said  by  com- 
petent operators  that 
this  type  of  fistula  is 
rarely  tubercular,  and 
my  experience  coin- 
cides with  this  o]3inion. 
The  posterior  variety 
is  generally  submuscu- 
lar,  in  that  it  is  above 
the  level  of  the  external  sphincter  and  jDasses  above  its  aponeurosis. 
The  anterior  variety  is  generally  subtegumentary,  owing  to  the  fact 
that  there  is  no  deep  cellular  tract  between  the  perineal  body  and 
the  anus.  The  fistulous  tract  may  therefore  be  of  considerable  depth 
at  each  side  of  the  perineal  body,  but  is  superficial  as  it  crosses  the 
anterior  commissure. 

Treatment. — The  anterior  variety  may  be  dealt  with  either  by  the 
open  method  or  by  excision  with  immediate  suture.  When  there  has 
not  been  much  burrowing  and  there  are  no  tracts  leading  into  the 
scrotum  and  crural  folds,  they  may  be  dissected  out  and  the  wounds 
closed.  This  is  generally  an  easy  operation  owing  to  the  fact  that 
fistulas  in  the  anterior  quadrants  of  the  rectum  usually  open  into  the 
rectum  quite  low  down,  and  ordinarily  have  no  deep,  burrowing  tracts 
that  extend  up  along  the  rectal  wall.  The  tract  generally  consists  in  a 
well-developed,  more  or  less  globular  cavity  on  each  side  of  the  perineal 
body  connected  by  a  narrow,  superficial  tract  that  runs  underneath 
the  skin  from  one  cavity  to  the  other,  and  resembles  a  curved  dumb- 


FiG.  148. — Tract  of  Horseshoe  Fistula  operated  on  in 
September,  1901. 


406 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


Fig.  149. — Dumb-bell  Fistula. 


bell  more  than  a  horseshoe  (Figs.  149,  150).     The  lateral  cavities  are 
not  very  deep,  being  ordinarily  limited  by  the  triangular  ligament. 

Excision  and  suture 
are  therefore  practica- 
ble, but  it  requires 
skill  and  a  complete 
knowledge  of  the  anat- 
omy of  the  parts  to 
avoid  the  blood-vessels 
and  nerves  which  trav- 
erse this  area.  Where 
the  condition  does  not 
warrant  an  attempt  at 
this  method  of  treat- 
ment, the  fistula 
should  be  laid  open  by 
careful  dissection,  the  ends  of  the  sphincter  muscle  being  cut  squarely 
across  and  pulled  to  one  side  while  the  cicatricial  tissue  is  removed. 
It  is  not  safe  to  use  the  cautery  freely  in  this  area  as  the  sloughing 
which  follows  it  may  implicate  the  urinary  organs,  but  gentle  curetting 
and  the  application  of  carbolic  acid  to  the  tract  may  be  safely  used. 
After  this  the  parts  should  be  packed  lightly  with  absorbent  gauze 
soaked  in  oil  and  balsam,  or  in  glycerin  and  ichthyol.  In  women  great 
judgment  must  be  exercised  in  this  class  of  cases  not  to  destroy  too 
much  of  the  perineal  body;  excision  and  immediate  suture  should  al- 
ways be  performed  if 
possible. 

In  the  posterior 
horseshoe  fistula  the 
internal  opening  is 
usually  situated  near 
the  posterior  commis- 
sure and  between  the 
two  sphincters.  It  is 
generally  of  considera- 
ble size,  and  can  be 
made  out  distinctly 
by  digital  touch.  The 
lateral  burrowings 
may  be  superficial,  but 
generally   they   extend 

deeply   into    the    ischio-rectal    fossa   upon    each    side.      The    external 
opening  may  be  upon  either  side,  or  there  may  be  openings  on  both 


Fig.  150. — Results  of  Operation  ix  precedixo  Case. 

The  little  pits  on  either  side  represent  retracted  ends  of  trans- 

versus  perinei  fibers. 


FISTULA  407 

sides.  The  cavities  in  such  fistulas  are  generally  so  irregular  that  ex- 
cision with  immediate  suture  is  not  very  practicable.  In  most  of  these 
cases  the  entire  fistulous  tract  around  the  posterior  commissure  of  the 
anus  is  laid  open  from  one  side  of  the  rectum  to  the  other,  always  carry- 
ing the  incision  in  the  skin  a  little  beyond  the  extremity  of  the  burrow- 
ing. After  this  has  been  done  and  the  parts  have  been  thoroughly 
scraped  out,  a  grooved  director  is  passed  from  the  incision  posteriorly 
through  the  fistulous  opening  into  the  rectum,  and  the  intervening  tis- 
sues are  cut  through.  Frequently  a  considerable  amount  of  dense, 
nodular,  cicatricial  tissue  is  found  at  this  point.  When  such  is  the 
case  it  should  be  dissected  out.  Goodsall  advises  allowing  the  fistulous 
tract  between  the  posterior  wound  and  the  rectum  to  remain  untouched, 
and  states  that  this  method  has  three  advantages,  viz.:  that  haemorrhage 
can  be  more  readily  controlled  by  plugging  the  wound;  that  when  the 
bowels  move  the  wound  will  not  be  soiled  by  the  escape  of  faeces  or 
flatus;  that  should  the  fistula  be  closed  without  the  division  of  the  ex- 
ternal sphincter  there  can  be  no  loss  of  power  even  in  that  muscle. 
Neither  hsemorrhage  nor  division  of  the  sphincter  at  this  point  are  ever 
serious,  and  soiling  by  fffical  material  is  not  so  inimical  to  healing  as 
constant  reinfection  from  a  fistulous  tract.  This  is  the  same  old  story 
which  has  been  so  often  told  in  the  treatment  of  fistula — an  attempt  to 
cure  the  condition  by  leaving  the  pathological  cause  untouched.  If  it 
were  necessary  to  choose  between  leaving  this  portion  or  the  lateral 
tracts  unopened,  by  all  means  select  the  latter,  as  complete  healing 
would  be  much  more  likely  to  take  place. 

Quenu  and  Hartmann  advise  laying  open  the  fistulous  tract  leading 
from  the  rectum  to  the  transverse  canal  by  an  incision  going  well  back 
toward  the  coccyx,  then  introducing  drainage-tubes  into  the  lateral  tracts 
and  keeping  them  washed  out  with  antiseptic  solutions.  They  claim 
to  have  obtained  excellent  results  by  this  method.  The  objection  to 
laying  open  all  the  lateral  tracts  at  the  same  time  that  the  fistula  is 
opened  lies  in  the  fact  that  sometimes  the  whole  anus  will  be  almost 
surrounded  by  the  incision,  thus  dissecting  it  loose  from  its  lateral  and 
posterior  attachments,  so  that  retraction  and  deformity  will  follow. 
While  this  deformity  does  not  result  in  incontinence,  it  produces  a  sort 
of  funnel-shaped  approach  to  the  anus  which  it  is  very  difficult  to  keep 
clean.  Besides  this,  the  large  cicatrices  are  occasionally  tender  and 
painful. 

Another  method  consists  in  cutting  through  the  fistulous  tract  into 
the  posterior  channel  connecting  the  lateral  cavities;  a  probe  is  then 
introduced  into  each  of  these  and  carried  circularly  forward  imtil  the 
end  rests  beneath  the  skin  at  its  anterior  limits;  counter-oi3enings  are 
made  at  these  points  and  two  or  three  strands  of  large-sized  silk  drawn 


408  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

through,  their  ends  tied  together  and  left  in  the  wound  as  a  sort  of 
seton.  The  sinuses  can  be  washed  out  dail}^  with  antiseptic  solutions; 
the  threads  should  be  left  in  for  ten  da3'S,  at  the  end  of  which  time 
healthy  granulation  will  develop  and  the  sinuses  will  heal  within  four 
or  five  weeks,  the  skin  overlying  them  remaining  perfectly  healthy, 
"Where  the  lateral  tracts  burrow  deeply  upward  instead  of  circularly 
around  the  rectum,  this  method  would  not  be  advisable.  Incision  and 
drainage  after  the  method  of  Quenu  and  Hartmann,  together  with 
cauterization  by  carbolic  acid  or  iodine,  or,  if  one  prefers,  by  the  sat- 
urated solution  of  nitrate  of  silver,  will  be  better. 

There  is  no  advantage  to  wait,  as  is  suggested  by  Goodsall,  for  two 
or  three  weeks  after  incising  the  fistulous  tract  before  applying  the 
cautery.  It  is  best  to  dry  out  the  wound  at  the  time  of  the  operation 
and  apply  the  cautery  then  and  there.  The  use  of  the  thermo-cautery 
in  deep  abscess  cavities  is  not  advisable  owing  to  the  fact  that  some- 
times extensive  sloughing  follows  this  operation,  and  if  the  instru- 
ment approaches  too  closely  to  the  wall  of  the  gut  necrosis  of  the 
tissues  may  take  place,  and  a  secondary  and  high  opening  may  be 
produced. 

After  the  fistula  has  healed,  if  the  retraction  of  the  rectum  causes 
any  great  inconvenience,  or  there  be  any  incontinence,  the  cicatrices 
may  be  dissected  out,  the  anus  loosened  from  its  new  attachment  and 
brought  down  and  sutured  in  its  normal  position. 

COMPLICATIONS    IN    OPERATIONS    FOR    FISTULA 

The  complications  likely  to  arise  in  operations  for  fistula  may  be 
divided  into  immediate  and  secondary.  The  immediate  are  those  that 
occur  during  the  operation,  and  the  secondary  those  that  occur  after 
it  is  finished. 

Immediate  Complications. — Discharge  of  Intestinal  Contents  over  the 
Operative  Field. — This  is  one  of  the  most  annoying  of  the  immediate 
complications.  The  introduction  of  a  large  sponge  into  the  rectum  is 
advised  to  provide  against  this  accident,  but  sometimes,  notwithstanding 
this,  the  intestinal  contents  will  be  forced  through  and  soil  the  wound. 
"VMien  the  accident  has  happened  in  operating  by  excision  with  immediate 
suture,  students  have  asked  whether  it  is  possible  to  obtain  immediate 
union  under  such  circumstances.  Reasoning  from  pathology  and  the 
knowledge  that  the  intestine  always  contains  a  certain  number  of  septic 
and  pyogenic  germs,  one  would  answer  this  question  in  the  negative; 
from  experience,  however,  it  is  known  that  facal  contamination  is  not 
always  fatal  to  primary  union  of  wounds  about  the  rectum.  Such  acci- 
dents can  be  largely  prevented  by  thoroughly  cleansing  out  the  bowels 


FISTULA  409 

the  clay  before  operation  and  practising  massage  over  the  descending 
colon  and  the  sigmoid  flexure  before  cleaning  the  parts,  at  the  same 
time  holding  the  anus  open  by  a  Sims's  speculum  and  a  rectal  retractor. 
By  these  means  the  contents  of  the  bowel  are  all  carried  down  into  the 
rectum,  and  can  be  washed  out  by  irrigation.  The  administration  of  a 
hypodermic  of  morphine  about  half  an  hour  before  the  operation  will 
also  assist  in  preventing  this  accident,  a  precaution  that  has  a  doubly 
beneficial  effect,  in  that  it  reduces  very  largely  the  amount  of  anaesthetic 
necessary,  and  also  controls  to  a  certain  degree  the  peristaltic  action 
of  the  bowels.  TiTien  the  discharge  once  occurs  the  operation  should  be 
stopped,  the  sponge  removed,  and  the  rectum  thoroughly  irrigated  with 
a  l-to-2,000  bichloride  solution.  The  rest  of  the  procedure  should  be 
carried  out  under  constant  irrigation  with  a  l-to-4,000  solution  of  the 
same  drug. 

Hcemorrhage. — Serious  loss  of  blood  during  an  operation  for  fistula 
is  rare  at  the  present  day.  There  are  so  many  means  of  hfemostasis  that 
it  is  seldom  one  will  meet  with  a  haemorrhage  which  he  can  not  control 
at  once. 

If  an  artery  be  cut  high  up  in  the  rectum,  it  can  be  grasped  by  long- 
pressure  forceps  and  held  until  a  ligature  can  be  thrown  around  it.  If 
the  tying  of  this  should  be  impossible,  the  forcejDs  may  be  left  on  for 
twenty-four  or  thirty-six  hours,  and  the  hemorrhage  will  be  completely 
controlled.  If  it  is  intended  under  such  circumstances  to  suture  the 
wound,  one  will  invariably  be  able  to  stop  the  haemorrhage  by  passing 
several  sutures  underneath  the  entire  wound  and  tying  them  tightly. 
Where  suturing  is  not  intended,  the  actual  cautery  applied  to  the  bleed- 
ing surfaces  will  effectually  control  the  hgemorrhage  and  in  a  sense 
sterilize  the  wound. 

In  cases  in  which  there  is  a  general  and  free  oozing,  it  may  be 
checked  by  the  use  of  hot  saline  solutions  applied  by  compresses  in  the 
wound.  It  is  well  to  have  such  oozing  checked  before  ajjphdng  the 
permanent  dressing,  and  except  in  rare  instances  the  patient  should  be 
kept  under  anaesthesia  until  this  has  been  accomplished. 

Spouting  vessels  should  be  controlled  by  torsion  or  ligature.  Many 
operators  depend  upon  firm  packing  of  the  wound  to  control  bleeding 
after  these  operations,  and  it  is  usually  satisfactory,  but  great  care  is 
necessary  in  applying  it  to  see  that  the  pressure  is  exerted  upon  the 
proper  tissues,  especially  when  the  wound  extends  well  up  in  the  rectum. 
It  should  be  remembered  that  the  chief  blood-vessels  lie  in  the  mucous 
and  submucous  tissues  and  not  in  the  deeper  layers  of  the  wound;  and 
that  if  the  edges  are  everted  and  the  pressure  is  not  brought  to  bear  upon 
them,  the  mouths  of  the  vessels  may  be  exposed  in  the  rectum,  and  thus 
the  bleeding  will  continue.     The  rectum  should  be  held  open  during  the 


410  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

dressing  by  a  duckbill  speculum  and  rectal  retractor,  in  order  tliat  tbe 
pressure  can  be  accurately  applied. 

Haemorrhage  is  very  likely  to  follow  operations  done  under  local 
cocaine  angesthesia.  As  is  well  known,  this  drug  contracts  the  arterioles 
to  such  an  extent  that  they  bleed  very  little;  and  so  long  as  its  effects 
last  one  may  have  an  almost  bloodless  wound,  whereas  after  its  influ- 
ence wears  away  the  parts  sometimes  bleed  excessively. 

It  is  important  therefore  when  one  operates  with  it  to  require  the 
patient  to  remain  quiet  for  one  or  two  hours  until  the  influence  of  the 
drug  has  entirely  disappeared;  after  this  the  superficial  dressings  should 
be  removed,  the  parts  examined,  and  if  there  is  any  evidence  of  bleeding 
the  wound  should  be  more  firmly  packed  or  the  vessels  tied. 

Another  point  which  it  is  necessary  to  remember  with  regard  to 
haemorrhage  is  the  possibility  of  a  ligature's  slipping  after  it  has  once 
been  applied.  This  may  be  due  to  the  fact  that  a  very  slight  hold  has 
been  taken  upon  the  vessels  in  the  first  place,  or  that  the  operator  has 
pushed  the  ligature  off  in  crowding  a  dressing  into  the  wound.  There 
is  no  necessity  or  advantage  in  the  applications  of  alum,  perchloride  of 
iron,  or  other  styptics  in  cases  of  this  kind;  they  all  irritate  the  parts, 
form  a  hard,  fragile  clot,  which,  when  the  dressings  are  removed,  is 
very  likely  to  slip  out  and  cause  hemorrhage  to  recur ;  they  delay  healing 
and  accomplish  nothing  which  can  not  be  done  by  plain  hot  water  or 
firm  pressure  from  dressings  properly  applied. 

Complications  of  Ancesthesia. — These  are  not  peculiar  to  rectal  opera- 
tions, and  need  not  be  entered  into  in  detail  here.  One  precaution,  how- 
ever, should  be  mentioned,  viz.,  in  administering  chloroform  the  mask 
should  always  be  removed  when  the  sphincter  is  stretched,  as  this  excites 
deep  respirations,  and  too  much  of  the  drug  may  be  inhaled  suddenly 
and  cause  fatal  results. 

Secondary  Complications. — The  secondary  complications  in  opera- 
tions for  fistula  are  described  as  early  and  late.  Of  the  early  complica- 
tions the  most  important  are  retention  of  urine,  involuntary  ftecal  pas- 
sages, shock,  and  sepsis. 

Retention  of  Urine. — There  is  nothing  peculiar  in  the  retention  of 
urine  following  operations  for  fistula.  It  is  of  the  same  character  as 
that  seen  after  almost  every  surgical  procedure  in  the  rectum. 

In  operations  about  the  anterior  quadrants  of  the  rectum  one  should 
always  remember  the  possibility  of  injuries  to  the  urethra,  and  also  the 
fact  that  much  manipulation  and  traumatism  of  these  parts  may  result 
in  an  acute  congestion  of  the  periurethral  tissues,  Avhich  will  cause  a 
temporary  oedema  and  constriction  of  the  urethral  canal.  In  such  cases 
it  will  sometimes  be  found  impossible  to  pass  an  ordinary  soft-rubber 
or  flexible  catheter  into  the  bladder,  and  one  should  always  be  provided 


FISTULA  411 

with  a  sterilized  silver  catheter  in  order  to  be  able  to  draw  the  urine. 
As  soon  as  the  congestion  subsides  these  symptoms  of  stricture  rapidly 
disappear.  It  is  advisable  to  induce  the  patient  to  urinate  if  possible 
before  attempting  to  catheterize  him,  even  if  he  has  to  stand  on  his 
feet  to  do  so.  It  is  well  to  wait  for  from  twelve  to  fourteen  hours  before 
resorting  to  the  catheter,  only  varying  this  rule  in  such  cases  as  suffer 
from  distention  of  the  bladder.  A  certain  amount  of  cystitis  and  atony 
of  the  bladder  may  be  developed  by  too  long  delay,  but  it  very  much 
more  frequently  occurs  as  a  result  of  too  frequent  and  too  early  cathe- 
terization, even  under  the  most  careful  antiseptic  precautions.  The 
catheter  itself  may  be  perfectly  sterilized,  the  operator  as  clean  as  anti- 
septics can  make  him,  and  yet  the  walls  of  the  anterior  and  deep  urethra 
can  not  be  sterilized,  and  the  slightest  traumatism  or  abrasion,  such  as 
may  be  produced  by  the  softest  instrument,  will  sometimes  set  up 
urethritis  and  cystitis  which  will  require  months  to  cure. 

Firm  packing  may  not  only  cause  retention  of  urine,  but  also  render 
the  passage  of  the  catheter  impossible.  When  this  occurs  the  dressings 
should  be  removed,  and  frequently  after  this  is  done  the  patient  can 
pass  urine  voluntarily.  In  all  cases  before  the  catheter  is  passed  the 
anterior  urethra  should  be  flushed  with  boric-acid  solution.  This  sub- 
ject is  more  fully  discussed  in  connection  with  operations  for  hemor- 
rhoids. 

Involuntmy  Defecation. — If  the  bowels  have  not  been  thoroughly 
emptied  before  the  operation,  the  patient  may  have  a  pressing  desire 
to  defecate  immediately  after  recovering  from  the  anaesthetic,  or  he 
may  even  do  so  involuntarily  before  consciousness  is  restored.  In  such 
cases,  if  excision  and  immediate  suture  has  been  practised,  the  parts 
should  be  irrigated  with  a  l-to-2,000  bichloride  solution,  gently  dried, 
and  the  dressings  reapplied.  If  the  open  method  has  been  practised, 
only  such  dressings  as  are  disturbed  or  soiled  by  the  passage  should  be 
removed. 

When  the  patient  after  becoming  conscious  complains  of  a  pressing 
desire  to  defecate,  one  should  not  insist  upon  controlling  it  too  long; 
a  concealed  hsemorrhage  in  the  rectum  will  sometimes  occasion  this,  and 
if  that  is  the  case  it  is  very  important  to  find  it  out  at  once;  therefore, 
when  the  desire  is  at  all  pressing,  the  superficial  dressings  should  be 
removed  and  the  patient  allowed  to  relieve  himself.  Occasionally  noth- 
ing more  than  a  small  amount  of  gas  or  a  little  fluid  will  come  away, 
but  no  harm  will  result  from  this,  and  it  will  remove  all  doubt  as  to 
concealed  hsemorrhage. 

Sliock. — Surgical  shock  may  follow  operations  for  fistula;  especially 
is  this  likely  if  the  patient  is  much  exhausted  from  long  suppurative 
processes,  or  if  the  operation  is  an  extensive  one  and  done  by  the  actual 


412  THE   ANUS,   RECTUM,  AND  PELVIC  COLON 

cautciy;  a  slight  hcVinorrhage  is  not  nearly  so  likely  to  produce  this  result 
as  deep  and  extensive  cauterization.  On  account  of  this  fact  the  use 
of  the  Paquelin  in  large  burrowing  tracts  with  great  destruction  of  tissue 
occurring  in  weak  and  debilitated  individuals  is  not  to  be  advised. 

The  symptoms  and  treatment  of  this  condition  are  laid  down  in 
every  work  upon  general  surgery,  and  do  not  differ  in  cases  following 
operations  upon  the  rectum,  except  in  one  point:  it  is  not  practicable 
to  employ  rectal  injections  of  hot  saline  solutions,  because  the  dressings 
would  have  to  be  removed  and  the  impairment  of  the  sphincter  would 
allow  the  fluid  to  come  away  at  once.  Hypodermoclysis  and  intravenous 
infusion  are  the  practical  means  of  treating  this  condition  in  these  cases. 

The  writer  is  a  firm  believer  in  the  use  of  large  doses  of  morphine 
in  surgical  shock,  excepting  where  the  kidneys  are  diseased.  It  quiets 
the  nervous  excitement,  reduces  the  frequency  and  increases  the  depth 
of  the  respiration,  and  is  at  the  same  time  more  or  less  of  a  heart  stimu- 
lant. Nitroglycerin  is  also  an  excellent  remedy  if  administered  in  doses 
sufficiently  large  to  produce  its  physiological  effect.  Hot  packs  and 
alcoholic  stimulants  are  also  useful.  For  general  instructions  upon  this 
subject,  however,  the  reader  is  referred  to  the  modern  works  upon  gen- 
eral surgery. 

Sepsis. — Acute  sepsis  sometimes  follows  operations  for  fistula.  It 
may  develop  within  the  first  few  hours,  and  does  not  often  do  so  later 
than  the  third  day.  When  it  occurs  it  assumes  the  form  of  diffuse  peri- 
proctitis, a  condition  which  has  been  already  described.  It  is  this  com- 
plication which  renders  it  imperative  to  take  every  antiseptic  precaution 
in  such  operations  notwithstanding  the  fact  that  pus  is  already  present. 
A  mild  form  of  sepsis  which  results  in  secondary  abscesses  is  sometimes 
seen.     In  these  cases  incision  and  drainage  is  the  rule  to  be  followed. 

Late  Complications. — Of  the  late  complications  in  operations  for 
fistula  the  most  important  are  incontinence  of  faeces,  extension  of  bur- 
rowing, irregularity  of  healing,  persistent  discharge,  and  partial  pro- 
lapse. 

Incontinence  of  Foeces. — This  condition  has  been  discussed  so  much 
that  it  has  become  a  nightmare  to  the  profession  and  a  stumbling-block 
to  every  layman  suffering  from  fistula.  It  is  the  shibboleth  of  the 
charlatan  by  which  he  frightens  the  suff'erer  away  from  the  regular  sur- 
geon and  induces  him  to  be  content  with  the  palliative  treatment  of  his 
condition  rather  than  submit  to  an  operation  accompanied  by  such  a  risk. 

It  does  not  occur  with  anything  like  the  frequency  that  is  generally 
attributed  to  it.  In  a  large  number  of  observations  the  author  has  met 
with  only  one  case  of  partial  incontinence  following  a  successful  opera- 
tion for  fistula  in  its  early  stages;  other  instances  have  resulted  from 
operations  upon  old,  extensive  fistulas  with  burrowing  tracts  or  multiple 


FISTULA 


413 


openings  which  have  been  long  neglected,  or  -which  have  been  imper- 
fectly operated  upon  in  the  beginning  and  failed  to  heal. 

Incontinence  may  result  from  simple  divulsion  of  the  sphincter,  but 
in  such  cases  it  is  associated  with  some  form  of  spinal  or  nerve  disease 
on  account  of  which  the  tonicity  of  the  muscles  is  not  properly  re- 
established. A  single  irregular,  diagonal,  or  jagged  incision  of  the 
sphincter  may  result  in  such  vicious  union  that  the  patient  will  not 
possess  normal  fsecal  control,  but  such  incisions  will  not  be  made  if  the 
technique  described  above  is  carried  out. 

Some  authors  hold  that  if  the  internal  sphincter  is  preserved,  one 
may  incise  the  external  in  any  direction  without  danger  of  incontinence 
(Fig.  151).  While  this  may  be  true  to  a  certain  extent  with  reference  to 
unconscious  faecal  passages,  it  certainly  is  not  so  with  reference  to  the 
voluntary  control.  A  patient  with 
the  external  sphincter  destroyed 
may  never  have  a  stool  unconscious- 
ly, but  when  the  contents  of  the 
intestine  reach  the  ampulla  of  the 
rectum,  it  will  be  impossible  to 
control  it  long  enough  for  him  to 
reach  the  toilet  if  the  stools  are 
thin  and  he  is  at  an  inconvenient 
distance.  The  integrity  of  the  ex- 
ternal sphincter  is  absolutely  neces- 
sary for  the  voluntary  control  of  the 
anus.  This  integrity  does  not  pre- 
clude the  possibility  of  the  muscle's 
having  been  severed  and  reunited. 
It  is  only  a  question  of  the  mus- 
cular fibers  uniting  end  to  end  or 
through  such  a  narrow  plane  of 
cicatricial  tissue  that  their  length 
will  not  be  materially  increased.  It  is  on  the  same  principle  as  a  fibrous 
union  between  two  fragments  of  a  fractured  patella.  If  the  fibrous 
union  is  narrow  and  firm,  functional  action  will  not  be  impaired.  If, 
however,  the  parts  are  united  by  long,  fibrous  bands,  the  functional 
action  of  the  vastus  muscle  will  be  practically  destroyed.  So  in  the 
sphincter,  when  its  fibers  have  been  incised  and  are  separated  by  wide 
cicatricial  masses,  the  length  is  so  increased  that  sutficient  contraction 
to  thoroughly  close  the  anus  is  practically  impossible.  Oblique  incisions 
of  the  muscle  allow  the  divided  ends  to  slide  upon  one  another,  thus 
lengthening  the  muscle  and  bringing  the  internal  fibers  of  one  end  in 
contact  with  the  external  fibers  of  the  other  (Fig.  152).    This  vicious 


Fig.  151. 
1,  oblique  incision  of  sphincter  which  is  fre- 
quently   followed    by    incontinence.       2, 
transverse  incision  not  likely  to  result  in 
same. 


414 


THE  ANUS,   RECrUM,  AND  PELVIC  COLON 


M 


\ 


union  is  always  followed  by  more  oi*  less  incontinence.  The  large  ma- 
jority of  cases  of  incontinence  following  operations  for  fistula  could  be 
avoided  if  the  external  sphincter  were  cut  squarely  across  and  the  ends 
sutured  together^,  or  the  packing  so  applied  as  to  separate  the  ends  yery 
slightly. 

"Where  the  fistula  passes  through  the  external  sphincter  muscle, 
involving  only  its  lower  portion,  these  fibers  may  be  severed  with  im- 
punity, and  the  necessity  of  suturing  may 
not  appear;  but  where  the  entire  external 
sphincter  is  cut  and  the  edges  of  the 
wound  retract  to  a  considerable  distance, 
one  must  always  be  prepared  to  meet  with 
a  certain  amount  of  incontinence  follow- 
ing the  operation. 

It  lias  been  claimed  that  incontinence 
never  results  from  a  single  incision  of  the 
sphincter  muscle,  but  this  statement  can 
not  be  substantiated.  It  is  not  a  ques- 
tion of  one  or  two  incisions  of  the  muscle 
so  much  as  it  is  of  a  close  and  accurate 
reunion.  The  muscle  may  be  cut  twice, 
three  times,  or  oftener,  and  if  it  be  im- 
mediately reunited  no  incontinence  will 
result.  A  number  of  cases  have  been  re- 
ported in  which  it  has  been  cut  at  two  or 
three  different  points  without  immediate 
suture,  and  without  any  incontinence  resulting.  The  reports  are  all 
too  meager  to  prove  that  the  entire  external  sphincter  was  severed;  it  is 
probable  tliat  in  the  majority  of  them  only  the  lower  segment  of  the 
muscle  was  cut.  Where  the  muscle  is  completely  severed  in  more  than 
one  place,  unless  it  be  immediately  sutured  the  retraction  will  necessitate 
such  a  wide  cicatricial  union  that  functional  activity  will  be  much  im- 
paired. There  are  cases,  it  is  true,  in  which  both  sphincters  have  been 
severed  at  several  points  or  entirely  removed,  and  in  which  the  anal 
outlet  and  lower  end  of  the  rectum  is  left  as  a  narrow,  cicatricial  canal, 
and  yet  these  patients  suffer  from  no  incontinence.  These  exceptions 
only  prove  the  rule. 

Wlien  the  external  sphincter  is  incised  more  than  once,  or  by  oblique 
incision,  or  where  the  ends  are  separated  in  union  by  a  wide  cicatrix, 
incontinence  will  almost  always  follow.  The  question  therefore  arises 
what  is  to  be  done  in  such  cases. 

Treatment. — "Where  the  incontinence  is  partial,  much  relief  may  be 
obtained  without  operative  interference.     Galvanism,  hot  fomentations. 


Fig.  152. 
On  the  left  is  shown  the  separation 
and  lengthening  of  the  muscle  {1 
to  f )  due  to  oblique  incision.  On 
the  right  is  seen  the  vicious  union 
of  the  fibers  and  tlie  line  of  inci- 
sion for  repairing  the  muscle. 


FISTULA 


415 


and  the  persistent  passage  of  mediimi-sized  bougies  have  some  influence 
in  hastening  the  absorption  of  cicatricial  dejDOsits,  and  will  sometimes 
entirely  cure  these  patients.  They  should  be  tried  in  all  such  cases 
before  resorting  to  operative  procedures. 

Operative  Treatment. — The  ideal  method  for  the  relief  of  inconti- 
nence consists  in  restoring  the  continuity  of  the  muscular  fibers.  The 
possibility  of  accomplishing  this  will  depend  first  upon  the  amount  of 
the  muscle  destroyed  by  the  original  operation  and  subsequent  sloughing 
of  the  tissues;  and,  secondly,  upon  the  length  of  time  which  has  elapsed 
since  the  operation.  Where  the  destruction  of  tissue  has  been  very 
great,  the  muscular  fibers  left  may  be  too  short  to  be  brought  into  con- 
tact. This  is  fortunately  not  often  the  case.  More  frequently  in- 
continence is  the  result  of  an  imperfect  and  irregular  union  of  the 
muscle,  as  exliibited  in  Fig.  152.  It  will  be  seen  in  such  cases  that 
the  union  of  the  fibers  allows  only  a  few  of  them  to  act  at  all;  that  the 
distance  between  the  fixed  portions  has  been  so  increased  that  the  ut- 
most contraction  will  not  close  the  anal  aperture,  and  that  the  cor- 
responding fibers  of  the  muscle  vrhich  have  been  incised  are  not  in  con- 
tact with  each  other.  The  operation  indicated  in  these  cases  is  short- 
ening the  muscle  and  bringing  into  normal  apposition  its  two  ends. 

The  method  usually  advised  to  accomplish  this  consists  in  freshening 
the  edges  by  taking  a  V-shaped  piece  out  of  the  angle,  as  is  shown  in 
Fig.  153,  and  suturing  the  parts  together.  It  is  perfectly  clear  that 
such  an  incision  will  not  shorten  the  elon- 
gated muscle  materially,  neither  will  it 
enable  one  to  bring  the  corresponding 
fibers  into  apposition  with  each  other.  If 
the  V-shaped  incision  is  inverted,  as  shown 
in  Fig.  153,  causing  the  two  legs  to  diverge 
outward,  thus  cutting  the  fibers  squarel}'' 
across,  the  muscle  will  be  shortened  and 
the  fibers  can  be  brought  into  a  compara- 
tively normal  apposition.  This  incision 
having  been  made,  the  tissues  intervening 
between  the  legs  of  the  incision  should  be 
excised,  the  ends  of  the  muscle  dissected 
out  and  sutured  squarely  together  by  chro- 
micized  catgut.  After  the  ends  have  been 
sutured  together,  it  is  well  to  pass  a  silver 

wire  or  catgut  tension  suture  through  the  skin  and  sphincter  muscle 
at  some  distance  from  the  incision,  carrying  it  across  the  wound 
and  out  through  the  muscle  and  skin  on  the  opposite  side.  After 
the  wound  has  been  closed  this  suture  should  be  tied  over  a  pad 


/ 


Fig.    153. — Old    Method    of    ke- 

PAIEING    SpHIIfCTEB. 


416  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

of  iodoform  gauze  so  as  to  prevent  tension  upon  the  sutures  that 
hold  the  ends  of  the  muscle  together  until  they  shall  have  suflicient 
time  to  unite;  it  is  allowed  to  remain  in  position  for  five  to  eight  days, 
according  to  the  amount  of  irritation  it  produces.  Another  plan  to 
accomplish  this  same  end  is  by  passing  around  the  anus,  on  a  level  with 
the  superior  border  of  the  external  sphincter,  a  buried  kangaroo  tendon, 
and,  tying  it  firmly  upon  the  index  finger,  introduce  it  into  the  anus 
as  is  done  in  the  operation  for  prolapse. 

In  this  operation  the  mucous  membrane  should  be  dissected  up  from 
the  muscle  before  the  latter  is  incised,  and  after  its  ends  are  brought  to- 
gether the  membrane  should  be  sutured  back  into  position;  none  of  it 
should  be  destroyed.  It  is  needless  to  say  that  it  is  important  to  check 
all  oozing  and  bring  together  the  deeper  portions  of  the  wound  from 
which  the  segment  of  cicatricial  and  muscular  tissues  has  been  excised, 
before  closing  the  incision. 

The  patient's  bowels  should  be  confined  for  six  to  eight  days  after 
such  an  operation,  at  which  time  they  should  be  induced  to  move  by 
injections  of  oil  and  glycerin  in  the  proportion  of  three  to  one.  These 
injections  should  be  repeated  twice  daily  until  all  the  hard,  f?ecal  masses 
have  been  removed,  after  which  time  the  patient  may  be  given  a  laxative 
by  the  mouth.  The  fact  that  a  patient  develops  an  elevation  of  tempera- 
ture of  1,  2,  or  3  degrees  during  this  period  of  constipation  should  not 
alarm  the  surgeon,  although  it  is  necessary  to  carefully  examine  the 
wound  dailj"  to  be  sure  that  no  suppuration  and  abscesses  form  in 
the  parts. 

"Wliere  sepsis  does  occur  and  a  small  abscess  develops,  it  is  not  neces- 
sary to  lay  the  whole  wound  open;  it  should  be  treated  simply  by  in- 
cision and  drainage  in  such  a  direction  that  the  united  ends  of  the 
sphincter  will  not  be  separated. 

Where  the  sphincter  muscle  has  been  divided  in  more  than  one  place, 
it  is  advisable  to  divide  the  operation  into  two  or  more  steps,  suturing 
at  the  first  sitting  all  the  incisions  upon  one  side,  and  leaving  those 
upon  the  other  for  a  future  operation.  By  attempting  to  unite  all  the 
parts  at  once,  too  great  tension  upon  the  ends  of  the  muscle  may  de- 
velop, and  too  much  inflammatory  reaction  may  be  set  up  in  the  parts 
for  proper  healing.  Where  the  operation  is  done  upon  one  side  alone 
little  tension  will  occur,  and  union  will  not  often  fail.  The  second 
operation  may  be  attempted  at  the  end  of  three  or  four  weeks  after 
the  first. 

The  patient  should  be  absolutely  confined  to  bed  after  such  an 
operation,  and  the  buttocks,  after  the  dressings  have  been  applied, 
should  be  strapped  together  with  a  broad  band  of  adhesive  plaster  in 
order  to  prevent  any  traction  upon  the  wound  which  might  occur  from 


FISTULA 


417 


these  parts  being  caught  and  dragged  upon  by  the  bed-clothing.  If  the 
internal  sphincter  has  been  divided,  its  ends  should  be  dissected  out 
and  sutured  together,  but  here  it  will  be  impossible  to  use  the  ten- 
sion suture. 

Where  incontinence  has  existed  for  long  periods  of  time,  the  mus- 
cular fibers  may  become  so  atrophied  that  it  will  be  impossible  to  recog- 
nize them  and  bring  their  ends  together.  Indeed,  they  become  degen- 
erated into  fibrous  tissue,  and  there  is  no  longer  any  real  muscle.  In 
such  cases  the  only  relief  which  can  be  expected  will  be  comparative. 
The  narrowing  of  the  anal  outlet  by  a  plastic  process  will  benefit  the 


Fig.  154. — Chetwood's  Opeeation  tor  Faecal  Ixcontixekce — First  Step. 


patient  considerably,  but  restoration  of  function  is  improbable.  This 
should  be  explained  to  the  patient  before  the  operation  is  undertaken  in 
order  to  avoid  disappointment. 

Chetwood,  of  New  York,  has  succeeded  in  restoring  the  functional 
activity  of  the  anus  in  a  case  of  this  kind  by  a  most  ingenious  plas- 
tic operation.  The  patient  suffered  from  absolute  incontinence,  and 
external  examination  revealed  no  evidence  of  the  existence  of  a 
sphincter. 

The  doctor  made  a  large  semicircular  incision  extending  from  one 
tuberosity  to  the  other,  its  convexity  being  directed  backward  toward 
the  coccyx  and  a  little  beyond  it  (Fig.  154).  The  flap  thus  made  was 
27 


418 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


Fig.  155. — Chetwi 


(  )l'ERATION SK' 


turned  forward,  and  the  fatty  tissue  dissected  away  until  the  lower  end 
of  the  rectum  at  the  edges  of  the  glutei  muscles  were  exposed.  A 
ribbon-shaped  piece  of  muscular  tissue  about  ^  of  an  inch  in  breadth 
and  yV  of  an  inch  in  thickness  was  then  dissected  from  the  glutei  mus- 
cles on  each  side,  leaving  an  attachment  at  the  coccyx.  These  ribbon- 
shaped  bands  were  made 
to  cross  each  other  be- 
neath the  ligamentous 
attachment  of  the  anus 
to  the  coccyx;  they  were 
then  made  to  encircle 
the  rectum  and  meet 
anteriorly  beneath  the 
skin,  the  cellular  tissue 
having  been  perforated 
by  dull  dissection.  At 
this  point  they  were  su- 
tured with  chromicized 
catgut  (Fig.  155).  A 
very  small  renmant  of 
sphincter  was  found  on  each  side  of  the  rectum,  and  to  this  the  new  mus- 
cular strips  were  attached  by  sutures.  The  original  flap  was  then  sutured 
back  in  position  and  the  wound  closed  with  aseptic  precautions.  Aside 
from  some  slight  sloughing  in  the  edges  of  the  wound  there  was  no  com- 
plication following  the  operation.  An  improvement  in  the  patient's 
continence  was  established  at  once,  and  one  year  later  the  newly  made 
sphincter  exercised  sufficient  control  on  the  bowel  to  retain  its  contents 
under  all  conditions. 

The  author  has  employed  this  method  in  five  cases;  in  three  the 
results  were  excellent,  in  two  little  improvement  was  obtained. 

Kelsey  advises  the  narrowing  of  the  anus  in  such  cases  by  the  appli- 
cation of  the  thermo-cautery  at  four  or  five  points  around  the  anus. 
The  cicatrices  produced  by  the  cauterization  are  often  tender,  irritable, 
and  occasion  considerable  suffering.  It  sometimes  happens  also  that 
this  process  of  cicatrization  involves  a  sensitive  nerve,  producing  a  peri- 
neuritis, and  is  followed  by  persistent  neuralgic  pain.  This  method  is 
therefore  to  be  avoided  if  it  is  possible  to  narrow  the  anal  outlet  by  a 
plastic  operation. 

Prolapse  of  licemorrhoids  and  Mucous  Membrane. — Occasionally  fol- 
lowing an  operation  for  fistula  the  patient  will  suffer  from  prolapse  of 
internal  hemorrhoids  or  mucous  membrane  into  the  fistulous  wound. 
The  hgemorrhoids  may  be  present  at  the  time  of  the  operation,  or  they 
may  develop  afterward.    Where  the  pile  or  the  fold  of  mucous  membrane 


FISTULA  410 

continually  protrudes  between  the  edges  of  the  wound  it  will  necessarily 
retard  or  prevent  healing. 

It  is  the  practice  of  some  operators  to  remove  them  at  the  time  of  the 
operation  for  fistula;  ordinarily  no  complication  follows  it,  but  occasion- 
ally the  hsemorrhoidal  wound  is  infected  by  the  pus  from  the  fistula, 
and  the  patients  suffer  from  long,  protracted  ulceration.  This  has 
usually  been  in  the  cases  in  which  the  fistula  was  very  recent  and  there 
was  a  considerable  amount  of  pus  in  the  abscess  cavity.  Therefore,  it 
is  advisable  to  make  this  distinction  in  such  cases:  where  the  fistula  is 
comparatively  acute,  and  there  is  considerable  suppuration  present,  no 
operation  should  be  performed  at  the  time  upon  existing  haemorrhoids. 
The  stretching  or  cutting  of  the  sphincter,  together  with  the  rest  in  a 
recumbent  posture,  will  probably  prevent  the  piles  becoming  congested, 
and  obviate  any  interference  with  the  healing  of  the  fistula.  If,  how- 
ever, one  well-developed  hsemorrhoidal  tumor  is  situated  right  above 
the  angle  of  the  wound,  it  may  be  removed  by  the  clamp  and  cautery 
at  the  time  of  operation  for  fistula,  but  it  is  better  not  to  interfere  with 
the  others. 

Where  the  fistula  is  chronic  and  associated  with  very  little  suppura- 
tion, if  the  operation  of  incision  is  to  be  done  the  haemorrhoids  may  be 
removed  at  the  same  time  with  impunity.  The  clamp  and  cautery  is 
by  all  means  the  best  method  to  employ  under  these  circumstances.  If 
excision  and  immediate  suture  are  to  be  done,  the  hasmorrhoids  may  be 
removed  at  the  same  time  by  the  Whitehead  method,  but  no  operation 
resulting  in  granulation  and  suppuration  such  as  the  clamp  and  cautery, 
or  the  ligature,  should  ever  be  employed  under  these  circumstances. 
If  after  an  operation  for  fistula  there  should  be  a  prolapse  of  the  mucous 
membrane  or  the  folding  in  of  the  mucous  flaps  of  the  wound  into  the 
fistulous  tract,  these  folds  should  be  removed  as  early  as  possible  either 
by  the  scissors  or  the  clamp. 

This  second  operation  may  be  performed  under  the  infiuence  of 
cocaine,  but  it  is  much  better  to  chloroform  the  patient  so  that  it  may 
be  thoroughly  done,  and  the  excision  carried  as  high  as  is  necessary. 

Protracted  Suppuration  and  Extension  of  Burrowing.— In  a  certain 
number  of  cases  after  operation  for  fistula  the  discharge  of  pus  will  not 
be  materially  lessened.  Occasionally  the  suppuration  will  be  protracted, 
on  account  of  the  general  unhealthy  condition  of  the  wound.  This  con- 
dition may  be  due  to  septic  germs  or  to  the  constitutional  state  of  the 
patient  due  to  syphilis,  etc. 

Bright's  disease,  diabetes,  cardiac  disease,  and  ansemia  are  also  causes 
of  protracted  healing  in  fistula.  These  conditions  should  always  be 
recognized  before  an  operation  is  done,  and  where  they  exist  in  a  marked 
degree  it  should  be  limited  to  the  least  possible  interference  consistent 


420  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

with  the  relief  of  the  patient's  sufferings.  An  incision  into  the  external 
tissues  large  enough  to  thoroughly  drain  the  fistulous  tract  is  all  that 
should  be  attempted  under  these  circumstances.  We  have  indicated 
already  the  course  of  procedure  in  cases  where  tuberculosis  is  responsible 
for  delayed  healing. 

Occasionally  after  an  operation  for  fistula,  extension  of  burrowing 
will  take  place  in  one  or  more  directions;  if  careful  examination  is  made 
it  will  be  found  due  to  the  fact  that  some  small  pocket  or  lateral  tract 
has  been  imperfectly  laid  open,  and  the  dressings  have  acted  as  a  plug, 
preventing  its  drainage.  Where  the  wound  has  been  drained  by  very 
light  packing  or  by  drainage-tubes,  such  extension  will  rarely  occur. 
If,  however,  it  does  take  place,  the  burrowing  tracts  should  be  freely 
laid  open  upon  the  skin  surface  to  a  distance  of  ^  an  inch  beyond  its 
deepest  portion,  and  drained  as  has  been  indicated  heretofore. 

Goodsall  says:  "  The  onset  of  pain  in  the  wound  after  the  first  eight- 
een hours  following  an  operation  upon  an  uncomplicated  fistula  is 
always  suggestive  of  extension  of  burrowing."  The  pain  in  these  cases 
is  of  a  throbbing,  aching  character,  and  is  associated  with  chill,  fever, 
and  swelling  in  the  neighborhood  of  the  wound,  resembling  very  much 
the  symptoms  of  acute  abscess.  Immediately  upon  the  appearance  of 
such  symptoms  early  after  the  operation,  the  dressings  should  be  re- 
moved, and  the  burrowing  tract  or  fresh  abscess  laid  open  and  drained. 

Premature  and  Irregular  Healing. — Frequently  after  an  operation  for 
fistula,  where  the  patient  is  not  carefully  attended  and  dressed,  the 
superficial  edges  of  the  wound  will  unite  before  the  deeper  portions  have 
contracted  and  filled  up  by  granulation,  thus  leaving  a  cavity  beneath 
them;  or,  owing  to  the  imperfect  application  of  the  dressings  the  parts 
will  be  drawn  out  of  shape  and  an  irregular,  puckered  union  will  take 
place.  Many  cases  of  fistula  recur  owing  to  these  accidents.  It  is  a 
condition  which  should  be  prevented  and  not  treated.  There  is  no 
operation  done  upon  the  rectum  which  requires  so  persistent  and  exten- 
sive after-treatment  as  that  for  fistula,  and  the  surgeon  who  is  the  most 
successful  in  the  cure  of  these  cases  will  always  be  found  to  be  the  one 
who  gives  his  personal  and  individual  attention  to  the  dressing  and  care 
of  his  patient. 

If  from  any  neglect  or  accident  the  upper  portions  of  the  wound 
should  unite  before  the  deeper  portions,  they  should  be  reincised  or  torn 
apart  by  the  introduction  of  the  prolje  or  index  finger. 

A  good  plan  to  avoid  such  an  accident  is,  when  operating  for  fistula 
by  the  method  of  incision,  to  trim  off  well  the  skin  and  mucous  edges 
of  the  wound  for  the  distance  of  ^  of  an  inch  throughout  its  extent. 
By  this  means  better  drainage  will  be  secured,  and  the  dangers  of  prema- 
ture union  of  the  edges  will  be  practically  eliminated. 


CHAPTER   XII 
COMPLICATED  FISTULA 

This  class  embraces  all  those  fistulas  which  connect  the  anus  and 
rectum  with  other  organs,  or  which  proceed  from  diseases  of  the  bones 
of  the  pelvis  and  spinal  column.  The  recognition  of  these  conditions 
is  very  necessary,  for  the  treatment  is  entirely  different  from  that  of 
other  types,  and  errors  in  diagnosis  may  end  disastrously. 

Fistulas  originating  in  Bone  Disease. — Tuberculosis,  osteosarcoma, 
and  necrosis  of  the  bones  of  the  pelvis  or  spinal  vertebrse  result  in 
abscesses  and  subsequent  fistulas  which  open  in  the  perianal  region  or 
into  the  rectum  itself.  Those  which  originate  in  disease  of  the  sacrum 
or  coccyx  find  outlets  in  the  posterior  quadrants  of  the  peringeum,  and 
involve  the  retro-rectal  space;  while  those  from  the  other  bones  of  the 
pelvis  or  the  vertebrse  usually  open  in  the  anterior  quadrants  of  the 
peringeum  or  into  the  rectum  itself;  but  occasionally  an  abscess  originat- 
ing in  the  lower  lumbar  vertebrge  burrows  down  between  the  folds  of 
the  peritonaeum  which  form  the  mesorectum,  and  thus  forms  a  fistula 
leading  into  the  retro-rectal  space. 

The  symptoms  in  such  conditions  are  never  those  of  acute  abscess 
with  chill,  fever,  pain,  and  swelling.  They  develop  as  cold  abscesses, 
manifesting  themselves  by  pain  in  the  spine  or  legs  with  dull,  heavy 
aching  in  the  pelvis,  interference  with  the  fsecal  and  urinary  passages, 
and  finally  present  or  break  at  some  point  around  the  anus  or  within 
the  rectum.  After  the  abscess  has  broken  into  the  rectum  it  may  still 
burrow  downward  and  open  upon  the  skin. 

The  point  at  which  the  rupture  into  the  intestine  occurs  is  very  vari- 
able.    It  may  be  anywhere,  from  the  internal  sphincter  to  the  upper, 
limits  of  the  pelvic  colon.     In  a  typical  case  of  this  kind  the  opening 
was  about  2  inches  above  the  recto-sigmoidal  juncture. 

J.  S.,  boy,  five  and  a  half  years  of  age,  suffering  from  tubercular  coxalgia, 
developed  at  first  a  small  subtegumentary  fistula  at  the  margin  of  the  anus.  This 
was  laid  open,  cauterized,  and  appeared  to  be  healing  without  complications, 
when  he  began  to  suffer  with  distention  of  the  abdomen,  difiiculty  in  ftecal  move- 
ments, and  dull  pains  in  the  pelvic  region,     The  tunaor  could  be  easily  felt  to  the 

421 


422  THE   ANUS,   RECTUM,  AND   PELVIC   COLON 

left  of  the  lumbo-sacral  juncture  through  the  abdominal  wall.  It  increased 
rapidly,  and  six  daj-s  after  it  was  discovered  the  child  "felt  something  break," 
and  shortly  afterward  had  a  movement  of  his  bowels  comjDOsed  entirely  of  pus, 
and  measuring,  according  to  the  mother's  statement,  fully  two  pints.  She 
brought  the  child  to  the  clinic  on  the  following  day,  and  while  the  external  sur- 
faces about  the  anus  appeared  to  be  perfectly  healthy  and  the  previous  wound 
healing  nicely,  the  rectum  was  found  to  be  full  of  creamy  pus.  Under  chloroform 
the  sphincter  was  stretched,  the  rectum  cleaned  out  and  searched  carefully  for  any 
point  from  which  the  pus  might  come,  but  in  vain.  With  the  tubular  speculum, 
however,  at  a  point  about  2  inches  above  the  recto-sigmoidal  juncture,  a  linear 
rent  about  ^  an  inch  in  length  was  found  in  the  bowel,  through  which  pus 
could  be  made  to  flow  by  pressure  upon  the  abdomen.  The  course  of  the 
abscess  was  doubtful,  and  manipulation  with  the  probe  at  so  great  a  distance 
might  penetrate  the  peritoneal  cavity,  so  the  parts  were  irrigated  as  gently  as 
possible  through  the  speculum,  which  was  then  withdrawn.  The  mother  was 
instructed  to  give  the  boy  full  enemata  of  saline  solution  daily,  but  not  to  purge 
him  under  any  consideration  lest  violent  peristaltic  action  should  tear  loose  the 
adhesions  and  produce  a  peritonitis.  The  pus  continued  to  be  discharged  from 
the  rectum,  until  four  weeks  later  the  child  began  to  complain  of  pain  in  walking, 
and  careful  examination  showed  a  deep  induration  to  the  left,  and  in  front  of  the 
rectum.  After  several  days'  poulticing  and  rest  in  bed,  it  was  possible  to  make 
out  this  swelling  through  the  perinseum.  After  deep  dissection,  a  large  pus 
cavity  was  found  and  opened.  After  this  the  discharge  of  pus  from  the  bowel 
became  rapidly  less,  and  ceased  entirely  wuthin  one  week.  Tuberculosis  of  the 
vertebrae  having  been  diagnosed  in  this  case,  the  source  of  the  pus  was  not  diffi- 
cult to  determine.  Under  constitutional  treatment,  continual  drainage,  and  irri- 
gation the  patient's  health  improved,  and  the  suppuration  largely  decreased,  but 
not  until  three  other  burrowing  tracts  had  occurred  in  the  buttocks  and  areund 
the  anus.  The  child  lived  for  two  years,  seemed  to  be  gaining  in  health  and 
strength,  and  all  the  fistulous  tracts,  save  one,  had  closed,  when  he  was  attacked 
with  pneumonia  following  measles,  and  died  at  the  age  of  seven  and  a  half  years. 
The  necrosis  in  this  case  was  seated  in  the  ninth  and  tenth  dorsal  vertebrae. 

The  writer  has  seen  a  case  of  fistula  passing  downward  and  in  front 
of  the  rectum,  originating  in  an  osteosarcoma  of  the  ilium.  An  autopsy 
upon  this  case  show-ed  that  the  fistulous  tract  had  burrowed  downward 
below  the  inferior  fascia  of  the  levator  ani  muscle,  passing  behind  the 
triangular  ligament,  and  opened  in  the  right  anterior  quadrant  about  1 
inch  from  the  anus.  The  fistulous  tract  approached  the  rental  wall  so 
nearly  that  nothing  more  than  the  mucous  membrane  seemed  to  separate 
the  two  cavities.  It  is  not  possible  to  give  any  statistics  in  regard  to 
the  frequency  of  fistula  in  diseases  of  the  vertebra,  but  to  judge  from 
the  number  which  appear  at  the  clinic  they  can  not  be  very  rare. 

Subtegumentary  fistula  posterior  to  the  anus  and  burrowing  upward 
over  the  surface  of  the  sacrum  is  not  infrequent.  It  may  sometimes 
be  due  to  necrosis  of  the  bones,  but  in  many  instances  it  is  not.  It  is 
said  by  some  authors  to  result  from  injuries  during  childbirth  and  falls 
or  blows  upon  the  coccyx.     The  author  has  seen  a  case  which  resulted 


COMPLICATED  FISTULA  423 

from  a  fall  'n'liile  skating  that  occurred  in  a  man  forty-five  years  of  age, 
and  was  evidently  due  to  necrosis  following  fracture  of  the  coccyx. 

The  -white^  creamy  character  of  the  pus,  its  profuseness  and  persist- 
ency, notwithstanding  free  drainage  and  antiseptic  irrigation,  together 
with  the  antecedent  history  of  the  case,  will  generally  indicate  the  nature 
of  such  fistulous  tracts. 

Treatment. — One  must  recognize  in  the  beginniag  that  the  large 
majority  of  these  cases  are  tuberculous,  and  conduct  the  treatment  upon 
these  lines.  The  only  operative  interference  justifiable  in  such  cases 
is  to  keep  the  tract  well  open  at  its  lowest  point  in  order  to  maintain 
drainage  and  prevent  further  burrowing.  If  the  diseased  bone  can  be 
reached  and  the  necrotic  tissues  scraped  out,  this  may  be  attempted; 
but  at  the  present  day  this  practice  is  opj^osed  by  many  competent  sur- 
geons, who  hold  that  where  the  entire  diseased  area  can  not  be  radically 
excised,  it  is  better  not  to  interfere  with  it  at  all,  but  depend  upon 
improving  the  patient's  constitutional  resistance  to  the  pathological 
processes.  Thorough  drainage,  the  support  of  the  diseased  parts  by 
proper  braces,  the  administration  of  tonics,  cod-liver  oil,  and  creosote, 
and  change  of  climate  will  do  more  for  these  cases  than  local  treatment 
or  surgical  operations. 

The  lines  of  incision  for  drainage  in  such  cases  are  the  same  as  those 
laid  down  for  other  types  of  fistula,  and  depend  upon  the  location  of 
the  external  opening.  The  sphincter  muscles  should  be  sedulously 
avoided,  as  their  reunion  is  almost  impossible  with  the  constant  flow  of 
pus  through  the  wound. 

Fistulas  connected  with  Other  Organs. — Ano-rectal  fistulas  connect- 
ing with  other  organs  have  been  very  properly  divided  into  the  urinary 
and  the  genital.  The  first  class  is  always  connected  with  some  part  of 
the  urinary  tract:  the  urethra,  the  bladder,  or  the  ureter.  They  are 
largely  confined  to  the  male  sex,  owing  to  the  fact  that  in  women  the 
bladder  and  urethra  are  separated  from  the  rectum  by  the  interposition 
of  the  uterus  and  vagina.  TMiile  it  would  be  practically  impossible  to 
have  a  recto-urethral  fistula  in  a  woman,  we  do  occasionally  see  recto- 
vesical fistula  in  this  sex.  There  is  rarely  a  simple  fistula  between  these 
two  organs,  however,  as  it  ordinarily  involves  the  vagina  as  well,  thus 
forming  a  recto-vesico-vaginal  fistula.  On  the  other  hand  the  genital 
fistulas  are  nearly  all  found  in  women.  Occasionally  one  sees  a  sub- 
tegumentary  fistula  burrowing  forward  into  the  scrotum,  but  such  cases 
have  no  distinguishing  features  beyond  the  fact  that  the}^  are  very  rare, 
and  always  superficial  in  the  anterior  portion  of  their  course.  They 
may  be  dismissed  with  the  remark  that  they  should  be  treated  by  inci- 
sion, or  better  still  by  excision  with  immediate  suture,  just  as  any  other 
subtegumentary  fistula  in  ano. 


424  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

"Urinary  Fistulas. — These  may  be  classified  as  perineal,  reeto- 
urethral,  recto-ureteral,  and  recto-vesical. 

Perineal  Fisiula. — Fistulas  in  the  perina?um  that  originate  in  the 
urinary  tract  sometimes  burrow  backward  and  open  at  some  point  around 
the  anus,  thus  simulating  ano-rectal  fistula.  They  usually  result  from 
some  disease  in  the  posterior  portion  of  the  bulbous  urethra  or  in  Cow- 
per's  glands.  It  will  be  remembered  from  our  anatomical  studies  that 
these  parts  are  included  between  the  layers  of  the  deep  and  superficial 
fasciae,  and  form  a  part  of  the  anterior  boundary  of  the  uro-genital  tri- 
angle. Abscesses  or  urinary  extravasation  occurring  in  this  space  may 
burrow  forward  around  the  anterior  margin  of  the  superficial  fascia  of 
the  perina?um,  and  thence  backward  beneath  the  skin  and  perineal  fascia, 
surrounding  the  anus  and  opening  at  points  which  make  them  appear 
as  ano-rectal  fistulas.  In  the  case  illustrated  (Fig.  123),  the  fistula  ap- 
peared to  be  of  the  horseshoe  variety  posterior  to  the  rectum,  and  almost 
completely  surrounded  this  organ.  Careful  dissection,  however,  revealed 
no  connection  between  the  fistulous  tract  and  the  latter  organ.  Two 
days  after  the  operation  urine  was  found  in  the  wound,  and  finally  the 
tract  was  traced  around  the  anterior  margin  of  the  superficial  fascia  of 
the  perinaeum  into  the  bulbous  urethra.  Such  cases  practically  belong 
to  genito-urinary  surgery,  but  it  is  very  important  to  recognize  them, 
and  thus  avoid  making  incisions  into  the  rectum  when  there  is  no  con- 
nection between  it  and  the  disease. 

Etiology. — The  causes  of  these  fistulas  are  diseases  of  the  urethra, 
traumatism  to  the  parts  from  a  kick,  blow,  fall,  or  more  frequently  from 
the  forcible  introduction  of  instruments.  False  passages  made  by  sounds 
or  small  urethral  instruments  in  cases  of  stricture  at  the  bulbous 
portion  of  the  canal  may  be  followed  by  abscess  of  the  perineal  space, 
as  may  also  suppurative  disease  of  this  part,  gonorrhoea,  or  tuberculosis 
of  Cowper's  glands,  and  the  extravasation  of  urine  through  a  rent  in  the 
urethral  wall,  and  such  abscesses  often  end  in  fistulas  which  simulate 
those  of  the  ano-rectal  type. 

Diagnosis. — In  these  cases  there  will  nearly  always  be  a  history  of 
gonorrhoea,  of  stricture,  or  of  traumatism.  The  patient  will  not  com- 
plain of  any  pain  in  the  anus  or  rectum  unless  the  fseces  are  very  hard. 
He  may  have  difficulty  of  urination,  and  sometimes  even  inability  to 
pass  urine  at  all;  there  will  generally  be  a  history  of  chill,  fever,  pain, 
and  swelling  preceding  the  discharge  of  pus  from  the  urethra  or  the 
opening  of  the  abscess  upon  the  skin;  the  finger  in  the  rectum  will  not 
elicit  any  induration  or  abnormality  in  this  organ,  but  if  bimanual  palpa- 
tion be  practised,  induration  in  the  perineal  body  can  be  easily  made  out. 
Examination  with  the  probe  will  show  that  the  deepest  portion  of  the 
fistula  is  always  anterior  to  the  line  between  the  two  ischii,  the  abscess 


COMPLICATED   FISTULA  425 

being  limited  posteriorly  by  the  triangular  ligament.  The  pus  in  these 
cases  is  never  feculent,  but  may  have  an  odor  of  urine.  Where  there 
is  any  doubt  with  regard  to  the  opening  in  the  urethra  several  methods 
of  diagnosis  may  be  adopted.  One  may  determine  this  by  passing  a 
sound  into  the  urethra  and  then  introducing  a  probe  into  the  fistula. 
If  the  metals  come  in  contact  the  urethral  opening  will  be  proved.  The 
urethra  may  be  suddenly  compressed  during  urination,  and  the  urine 
thus  forced  out  into  the  wound  can  be  recognized  by  chemical  tests. 
This  method  was  employed  in  the  case  mentioned. 

A  simpler  method  consists  in  administering  to  the  patient  a  small 
capsule  of  methylene  blue;  after  a  few  hours  the  urine  will  be  stained 
with  this  material,  and  if  it  discharges  into  the  abscess  cavity  there  will 
be  no  difficulty  in  recognizing  the  fact.  Where  no  urine  passes  into 
the  fistulous  tract  one  may  safely  conclude  that  the  disease  has  origi- 
nated outside  of  the  urethra,  either  in  the  glands  of  Cowper  or  the 
perineal  lymphatics. 

The  chief  point  in  the  diagnosis  consists  in  determining  the  extra- 
rectal  origin  of  the  fistula,  and  as  a  general  rule  for  this,  one  may  say 
abscesses  which  develop  anterior  to  the  transversus  perinei  muscles 
rarely  have  any  primary  connection  with  the  rectum. 

Treatment. — The  abscess  or  fistulous  tract  should  be  treated  by  drain- 
age, curettage,  and  cauterization,  such  as  has  been  advised  in  the  treat- 
ment of  ano-rectal  fistula;  but  one  should  be  careful  in  nsing  strong 
cauterizing  agents  lest  they  invade  the  urethra  and  bladder,  and  thus 
set  up  an  acute  cystitis  or  urethritis.  Where  a  stricture  of  the  urethra 
is  present,  it  is  important  that  this  should  be  dilated  or  incised  before 
any  attempt  is  made  to  heal  the  fistula.  All  suppurating  conditions  of 
the  urethra  should  be  overcome,  and  the  urine  rendered  as  non-irritating 
as  possible.  It  may  be  a  wise  plan  during  the. first  two  or  three  weeks 
of  such  treatment  to  catheterize  the  patient  at  stated  intervals,  never 
allowing  any  urine  to  pass  through  the  urethra,  and  thus  into  the  wound. 
The  frequent  passage  of  the  catheter,  however,  may  do  more  to  retard 
the  healing  and  keep  up  the  inflammation  than  does  the  escape  of  a  little 
urine.  What  concerns  us  most  in  the  present  discussion  is  the  fistulous 
tract  and  its  biirrowing  around  the  anus.  With  regard  to  this  nothing 
more  need  be  said  than  that  excision  with  immediate  suture  is  not  likely, 
to  prove  successful  in  these  cases  on  account  of  the  urethral  discharge; 
therefore  they  had  better  be  treated  by  simple  incision,  or  if  the  case 
be  of  a  tubercular  nature,  incision  by  the  thermo-cautery  and  cauteriza- 
tion of  the  fistulous  tract  would  be  the  proper  course  to  pursue. 

Recto-urethral  Fistula. — This  condition,  as  its  name  implies,  con- 
sists in  an  abnormal  communication  between  the  urethra  and  the  rec- 
tum.    It  always  involves  the  membranous  or  prostatic  portion  of  the 


426 


THE   ANUS,  RECTUM,  AND   PELVIC   COLON 


uretlira,  and  usually  the  rectal  opening  is  above  the  external  sphincter. 
The  condition;,  while  comparatively  rare,  occurs  sufficiently  often  to 

deserve  a  detailed  con- 
sideration from  the  fact 
that  until  recently  no 
method  had  been  de- 
vised which  offered  any 
assurance  of  its  cure. 
The  term  uretliro-rec- 
tal  fistula  would  per- 
haps be  more  accurate, 
inasmuch  as  the  major- 
ity of  them  originate  in 
the  urethra,  and  lead 
from  this  cavity  back- 
Ward  and  downward 
into  the  rectum.  More- 
over, the  urine  escapes 
into  the  rectum  much 
more  frequently  than 
the  intestinal  contents 
into  the  urethra.  This 
is  not  due,  however,  to 
the  course  of  the  fistula 
so  much  as  to  the  size 
of  the  tract.  The  down- 
ward and  backward  di- 
rection of  the  tract  is 
by  no  means  invariable. 
In  10  cases  seen  by  the 
writer,  3  of  the  fistu- 
lous tracts  extended  from  the  rectum  downward  and  forward  into  the 
urethra  (Fig.  156).  In  these  cases  it  was  probable  that  the  fistula  had 
its  origin  in  the  rectum,  and  hence  the  direction  of  the  tract  may  in 
a  manner  indicate  its  source. 

Etiology. — Traumatism  and  pathological  processes  may  each  account 
for  these  fistulas;  they  are  therefore  classified  as  traumatic  and  patho- 
logical. Of  the  traumatic  variety  the  most  frequent  causes  are  false 
passages  or  punctures  made  by  sounds  or  other  instruments  introduced 
through  the  urethra;  small  filiform  bougies  or  pointed  catheters  may  be 
arrested  in  the  diverticula  of  the  membranous  or  prostatic  urethra, 
penetrate  the  same,  and  invade  the  recto-urethral  saptum,  or  even  per- 
forate the  rectal  wall,  thus  causing  at  once  a  complete  fistula.    It  is  not 


Fig.  156. — Eecto-urethral  Fistula. 

i,  tract  running  downward  and  backward,  probably  origi- 
nating in  urethra;  2,  tract  running  downward  and  for- 
ward, probably  originating  in  rectum. 


COMPLICATED  FISTULA  427 

necessary  that  complete  penetration  shonld  take  place  in  order  that  a 
fistula  may  result;  if  the  urethral  wall  be  torn,  the  abscess  which  follows 
extravasation  of  urine  into  the  dividing  septum  will  in  all  likelihood 
break  through  into  the  rectum,  this  being  the  direction  of  least  resist- 
ance as  compared  with  the  dense  tissues  of  the  perinfeum. 

Internal  urethrotomy  or  the  divulsion  of  stricture  in  the  membranous 
or  prostatic  urethra,  operations  for  stone  or  enlarged  prostate  have  all 
resulted  in  fistulas  between  the  rectum  and  urethra.  Fortimately  most 
of  these  cases  heal  spontaneously  owing  to  the  free  drainage  of  urine 
through  the  perineal  incisions.  Foreign  bodies,  such  as  pins,  needles, 
pipe-stems,  or  fish-bones  may  pass  from  the  rectum  into  the  urethra,  or 
vice  versa.  Traumatism  of  the  perineum  that  causes  extensive  slough- 
ing, and  impaling  upon  sharp  instruments  may  also  result  in  this  condi- 
tion, as  has  been  shown  by  Legueu  (Annales  des  maladies  des  organes 
genito-u.rinaires,  1893,  p.  300).  Eupture  of  the  urethra  in  consequence 
of  falls  or  crushing  accidents  may  cause  it,  as  may  gunshot  wounds. 
The  writer  has  twice  seen  the  accident  follow  excision  of  the  prostate, 
and  in  one  case  result  from  an  operation  for  haemorrhoids. 

Cancer  of  the  rectum  or  prostate  may  by  extension  or  sloughing 
result  in  a  communication  between  the  two  organs;  the  communication 
in  this  disease  is  not  nearly  so  frequent  as  it  is  between  the  bladder  and 
the  rectum,  where  it  forms  a  recto-vesical  fistula.  This  complication 
only  occurs  in  very  late  stages  of  the  malignant  disease. 

Tubercular,  syphilitic,  or  simple  ulcerations  of  the  rectum  may  result 
in  recto-urethral  fistula  through  extension  or  through  the  formation  of 
burrowing  abscesses  which  eventually  form  communications  between 
the  two  cavities.  It  is  very  rare,  however,  that  these  fistulas  originate 
upon  the  side  of  the  rectum.  As  has  been  stated,  abscesses  of  the 
superior  pelvi-rectal  space  rarely  originate  in  the  rectum,  and  therefore 
when  recto-urethral  fistulas  result  from  these,  the  pathological  cause  is 
still  to  be  sought  in  the  genito-urinary  apparatus.  In  tuberculosis  of 
the  rectum  the  prostate  gland  is  nearly  always  involved  in  the  same 
pathological  processes,  and  it  is  impossible  to  say  in  which  organ  the 
fistula  originates. 

Diseases  of  the  prostatic  and  membranous  urethra  are  the  etiological 
factors  in  the  large  majority  of  recto-urethral  fistulas.  Of  these  stric- 
ture is  the  most  frequent.  The  mucous  lining  being  destroyed  and  the 
wall  of  the  urethra  weakened,  the  obstruction  to  the  current  during 
micturition  forces  the  urine  out  into  the  peri-urethral  tissues,  and  it 
carries  the  pyogenic  bacteria  present  in  the  canal;  these  organisms  cause 
abscess  which  extends  in  the  direction  of  the  least  resistance,  frequently 
high  up  in  the  pelvi-rectal  space,  but  sometimes  directly  through  into 
the  rectum.     In  the  first  instance  if  the  abscess  opens  into  the  rectum 


428  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

the  resulting  fistula  will  be  indirect,  long,  and  tortuous;  in  the  "second, 
it  will  be  short  and  direct. 

Abscesses  of  the  prostate,  whether  simple,  gonorrhoeal,  or  tubercular, 
may  result  in  this  form  of  fistula;  the  capsule  of  the  gland  will  prevent 
much  burrowing,  and  the  fistulous  tracts  will  usually  be  direct  and  very 
short.  They  may  open  into  the  urethra  first,  and  afterward  invade  the 
rectal  canal,  or  the  process  may  be  reversed.  Where  they  open  into  the 
urethra  the  danger  that  recto-urethral  fistula  will  result  will  be  much 
less  than  in  those  cases  where  the  abscess  breaks  first  into  the  rectal 
cavity.  This  fact  emphasizes  the  danger  of  opening  such  abscesses 
through  the  rectum,  if  there  were  no  other  reasons  for  condemning  the 
procedure.  Forgue  (quoted  by  White  and  Martin)  states  that  43  out 
of  a  total  of  67  prostatic  abscesses  opened  into  the  rectum,  and  in  21 
of  these  pus  was  discharged  by  both  rectum  and  urethra.*  If  these 
figures  are  correct,  it  is  surprising  that  we  have  so  few  recto-urethral 
fistulas.  Sometimes  there  is  burrowing  in  these  cases,  and  the  openings 
into  the  rectum  and  urethra  may  be  complicated  b}^  one  in  the  perinseum 
or  by  blind  lateral  tracts. 

Finally,  calculi  of  the  prostatic  and  membranous  urethra  or  of  the 
prostate  itself  are  also  occasionally  the  cause  of  this  condition.  In  these 
instances  the  fistula  may  be  produced  by  the  sharp  point  of  the  stone 
cutting  through  the  urethro-rectal  septum,  or  by  pressure  ulceration, 
extravasation  of  urine,  abscess,  and  breaking  down  of  the  walls. 

Congenital  recto-urethral  fistulas  have  been  observed,  but  they  be- 
long to  the  tj^e  of  malformations.  They  are  due  to  the  absorption  of 
the  recto-urethral  instead  of  the  recto-anal  septum  in  foetal  life.  When 
the  normal  anal  orifice  is  established,  the  recto-urethral  fistula  will  gen- 
erally close  spontaneously. 

Symptoms  and  Diagnosis. — The  characteristic  symptoms  of  recto- 
urethral  fistula  are  the  passage  of  urine  into  the  rectum  or  of  gas  and 
intestinal  contents  into  the  urethra.  Both  rarely  occur  in  the  same 
individual.  The  direction  of  the  tract  will  determine  the  nature  of  the 
abnormal  passages.  The  latter  take  place  at  the  time  of  urination  or 
defecation.  The  amount  of  such  discharges  will  depend  upon  the  size  of 
the  opening,  the  length  and  direction  of  the  fistulous  tract,  and  the 
amount  of  obstruction  in  the  natural  channel.  A  tight  stricture  of  the 
urethra  causes  an  excessive  fiow  of  urine  into  the  rectum,  and  a  spas- 
modic sphincter  will  result  in  an  increased  amount  of  fgecal  matter  being 
passed  into  the  urethra.  Escape  of  the  intestinal  contents  into  this 
canal  is  much  less  frequent  than  that  of  the  urine  into  the  rectum;  this 
is  accounted  for  by  the  prevailing  direction  of  the  fistulous  tract,  which 

*  The  same  figures  are  attributed  to  Segoiui.     As  the  author  has  been  unable  to 
obtain  the  original  articles,  he  can  not  state  which  reference  is  correct. 


COMPLICATED  FISTULA  429 

is  do'O'nward  and  backAvard;  by  the  size  of  tlie  orifice,  wliicli  is  generally 
too  small  to  admit  any  but  fluid  materials;  and  finally  by  the  fact  that 
the  s^ohincters  are  not  frequently  so  contracted  as  to  produce  much  ob- 
struction to  fluid  or  semifluid  materials.  Sometimes,  however,  gas  and 
fffical  matter  are  forced  into  the  urethra,  and  even  solid  masses  have 
been  known  to  pass  through  the  canal  after  much  straining  and  pain. 
In  such  cases  there  is  alwa^^s  a  large  rectal  opening,  and  the  fistulous 
tract  is  short.  When  the  urine  passes  into  the  rectum  it  is  generally 
expelled  innnediately  thereafter,  owing  to  the  intolerance  by  the  rectal 
mucous  membrane  of  this  secretion.  Sometimes  this  is  not  the  case, 
and  it  is  retained  until  the  next  defecation.  In  such  instances  it  is 
difficult  to  distinguish  between  this  disease  and  recto-vesical  fistula. 
In  the  early  stages  there  is  always  a  discharge  of  pus  from  the  rectum 
and  urethra,  but  later  on  these  cease  almost  entirely.  In  short  fistulas 
the  mucous  membrane  of  the  rectum  becomes  continuous  with  that 
of  the  urethra.  Bernard  has  reported  a  case  that  occurred  in  the 
practice  of  Lallemand,  in  which  the  semen  was  expelled  through  the 
anus  without  any  previous  erection;  in  one  of  the  cases  in  which  the 
writer  operated,  spermatozoa  were  found  in  the  pus  collected  from  the 
rectum. 

Eectitis  and  urethritis  are  constant  symptoms  in  this  disease.  There 
is  often  diarrhcea  and  frequent  micturition.  According  to  Eichet,  the 
sphincter  muscle  loses  its  control,  and  Legueu  states  that  the  skin  upon 
the  buttocks  and  perinseum  becomes  excoriated,  though  in  the  cases 
which  the  author  has  seen  neither  of  these  comjDlications  has  been  ob- 
served. In  one  case  there  was  a  marked  cystitis,  and  a  swollen,  cedema- 
tous  condition  of  the  urethral  meatus. 

Digital  examination  will  always  reveal  the  rectal  opening,  and  where 
this  is  large  enough  to  admit  the  tip  of  the  finger,  a  sound  intro- 
duced through  the  urethra  can  be  easily  felt.  If  the  opening  is  small 
it  will  generally  be  surrounded  by  a  considerable  mass  of  cicatricial 
tissue;  it  may  be  in  the  shape  of  a  pouting  tubercle,  or  a  depressed, 
crater-like  cavity,  but  in  either  case  the  reed-like  tract  of  the  fistula 
may  be  felt  beneath  the  mucous  membrane  of  the  rectum,  running 
up  to  the  urethra.  By  the  aid  of  a  fenestrated  or  Sims's  speculum  the 
orifice  can  be  brought  into  view  and  a  probe  passed  into  it.  Usually 
there  is  no  difficulty  in  bringing  the  latter  into  contact  with  a  metallic 
sound  passed  into  the  urethra.  Sometimes  the  orifice  is  hidden  in  the 
folds  of  the  rectum  or  within  an  anterior  rectocele;  in  such  cases  the 
lar3Tigeal  mirror  may  be  of  service  in  discovering  it.  The  only  condition 
with  which  this  disease  is  likely  to  be  confounded  is  that  of  recto- 
vesical fistula.  The  diagnosis  between  these  two  conditions  may  be 
thus  stated. 


430  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

Eecto-urethral  Fistula  Recto-vesical  Fistula 

Rarely  congenital.  Comparatively  often  congenital. 

History  of  urethral  or  prostatic  disease.  History  of  peritonitis  or  intestinal  disease. 

Contents  pass  from  one  channel  to  the  Contents  pass  abnormally  without  regard 

other  only  during  functional  action.  to  functional  action. 

Amount  of  material  passed  is  small  and  Amount  of  material  passed  is  large  and 

irregular.  constant. 

Discharge  is  generally  from  the  urethra  Discharge  is  nearly  always  from  the  in- 

into  the  rectum.  testine  into  the  bladder. 

Cystitis  and  frequent  micturition  rare.  Cystitis  and  frequent  micturition  always 

present. 
Opening  in  rectum  generally  small  and  Rectal  opening  generally  large  and  above- 
low  down.  the  reach  of  the  finger. 
Sound  in  urethra  can  be  felt  by  probe  or  Sound  in  urethra  can  not  be  felt  through 

finger  in  rectum.  rectum. 

Colored  fluids  injected  into  bladder  do  Colored  fluids  ajjpear  in  rectum  iinmedi- 

not  appear  in  rectum  until  micturition  ately  after  injection  into  bladder. 

takes  place. 

Deposit  of  cicatricial  connective  tissue  is  Deposit  of   cicatricial  connective  tissue 

generally   large   and   easily   felt   with  generally  small  and  above  the  reach  of 

finger  in  rectum.  the  finger. 

The  prognosis  of  recto-urethral  fistulas  is  favorable  in  those  cases 
which  result  from  operative  procedures.  Where  they  result  from  patlio- 
logical  processes,  however,  there  is  little  or  no  tendency  to  spontaneous 
healing,  and  until  recently  all  the  methods  advised  failed  in  the  large 
majority  of  cases  to  close  the  communication  between  the  cavities. 

Treatment. — The  treatment  of  recto-urethral  fistula  has  been  as  vari- 
ous as  it  has  been  unsuccessful.  Writers  of  text-books  upon  surgery 
and  diseases  of  the  rectum  recommend  methods  with  which  they  have 
had  no  experience,  and  in  which  they  have  little  confidence.  Duplay 
(Am.  Encyc.  Surg.,  vol.  vi,  p.  507)  says:  "While  traumatic  fistulas  and 
those  which  follow  acute  and  tolerably  circumscribed  abscesses  present 
a  good  prospect  of  recovery,  fistulas  which  follow  in  the  train  of  diffuse 
and  extensive  suppuration,  either  idiopathic  or  of  a  tubercular  nature, 
and  which  are  accompanied  by  prostatic  sinuses,  are  almost  always  incur- 
able." And  again  (Traite  de  path,  extern.,  t.  vii,  p.  180)  he  says:  "  On 
the  whole,  if  we  had  any  examples  of  spontaneoi;s  cure  of  urethro-rectal 
fistula  we  might  counsel  that  it  is  best  to  wait,  as  the  chances  of  surgical 
interference  are  very  slight." 

Sir  Henry  Thompson  concludes  from  an  enormous  experience  that 
surgical  intervention  is  rarely  of  great  benefit,  and  that  constant  cath- 
eterization offers  the  best  prospect  of  cure.  He  advises  the  use  of  the 
galvano-cautery,  but  frankly  admits  that  he  has  never  cured  a  case  with 
it.  Morris  (Treves's  Syst.  of  Surg.,  vol.  ii,  p.  898)  advises,  from  a  theo- 
retical point  of  view,  catheterization  and  the  splitting  and  scraping  of 
the  fistulous  tract;  he  rejDorts  no  cases  as  cured,  but  states  that  he  has 


COMPLICATED  FISTULA  431 

benefited  one  by  supraj^ubic  cystotomy.  Quenu  and  Hartmann  ascribe 
excellent  results  to  the  ojoeration  of  Sir  Astley  Cooper,  but  we  have 
found  only  1  case  in  which  it  has  ever  succeeded. 

The  author  (Mathe^vs's  Med.  Quarterly,  April,  1898)  collected  25 
cases  of  this  condition,  8  of  which  were  cured  by  operative  methods, 
and  4  by  palliative  methods.  The  latter  i  were  all  acute  cases.  Xo 
chronic  case,  so  far  as  can  be  learned,  with  possibly  the  exception  of 
Thompson's,  has  ever  been  cured  by  cauterization  or  stionulation,  and 
surgeons  can  expect  little  from  this  mode  of  treatment.  In  the  paper 
referred  to,  the  writer  reported  3  cases  operated  upon  by  a  modified 
technicjue,  all  successfully;  since  that  time  he  has  operated  successfully 
upon  0  others,  and  assisted  in  1,  thus  making  a  total  of  9  cases.  In  the 
case  in  which  he  assisted,  the  operation  was  not  so  successful,  owing 
to  a  mistake  of  the  house-surgeon,  which  will  be  detailed  later. 

The  two  principles  upon  which  the  successful  treatment  of  these 
fistulas  depend  are:  first,  the  removal  of  all  obstructions  to  the  passage 
of  urine  or  intestinal  contents  through  their  normal  channels;  second, 
the  obliteration  of  the  fistulous  tract. 

So  long  as  a  stricture  of  the  urethra  remains  no  hope  can  be  enter- 
tained of  curing  the  fistula.  For  the  method  of  treatment  of  stricture 
the  reader  is  referred  to  the  works  on  genito-urinary  surgerv,  and  to  a 
brief  article  upon  this  subject  by  the  author  (X.  Y.  Medical  Journal, 
April  13,  1895). 

Wherever  there  is  hypertrophy  and  spasmodic  contraction  of  the 
sphincter  ani,  or  obstruction  to  the  passage  of  f»cal  matter  by  tumors, 
strictures,  or  other  conditions  of  the  rectum,  it  is  necessary  to  remedy 
these  before  attempting  any  direct  treatment  of  the  fistula.  Forcible 
dilatation  of  the  sphincter  will  overcome  spasm  temporarily,  but  its 
results  are  too  transitory  to  be  depended  upon  in  the  treatment  of  so 
serious  a  condition.  Absolute  relaxation  for  a  considerable  period  is 
necessary  in  these  cases,  and  this  can  only  be  obtained  by  incision  of  the 
muscle.  All  obstructions  having  been  removed,  the  parts  should  be 
protected  from  the  abnormal  passages  of  urine  into  the  rectum  and  of 
fffical  matter  and  gas  into  the  urethra.  Permanent  or  periodical  cath- 
eterization will  accomplish  the  first  of  these.  Many  ingenious  mechani- 
cal appliances,  such  as  oesophageal  tubes,  cannulas  with  aprons  attached, 
and  various  methods  of  packing  the  anterior  rectum  and  fistulous  open- 
ing with  non-absorbent  materials  have  been  devised,  but  none  of  them 
has  proved  successful  in  preventing  the  escape  of  gas  and  faeces  into 
the  urethra.  Allowing  the  bowels  to  move  only  once  in  four  or  five  days 
is  perhaps  the  best  method  to  prevent  this,  unless  one  wishes  to  resort 
to  the  diversion  of  the  fa?cal  current  through  an  inguinal  anus.  This 
last  measure  has  been  considered  too  formidable,  and  is  decried  by  most 


432  THE  ANtJS,  RECTUM,  AND   PELVIC  COLON 

operatoi's  and  ])atients.  Since  it  lias  been  demonstrated  that  the  opera- 
tion is  comparatively  without  danger,  and  the  anus  can  be  safely  and 
permanently  closed  without  opening  the  peritonseum  the  second  time,  it 
is  looked  upon  more  favorably,  and  would  be  entirely  justifiable  in  those 
cases  where  other  methods  have  failed,  or  as  a  preliminary  measure  to 
other  operations  under  certain  conditions.  As  will  be  observed  in  the 
paper  referred  to,  this  method  was  utilized  by  the  author  in  one  case 
on  account  of  extensive  rectal  ulceration;  the  result  was  satisfactory 
and  permanent. 

Treatment  of  the  Fistulous  Tract  Itself. — While  the  urethral  stricture 
is  being  dilated  or  otherwise  treated,  antiseptic  washing  and  stinmlating 
applications  by  such  substances  as  nitrate  of  silver,  chloride  of  zinc, 
iodine,  or  even  the  galvano-cautery,  as  advised  by  Sir  Henry  Thompson 
and  M.  Dentu,  may  be  used  with  the  hope  of  narrowing  the  fistulous  open- 
ing, if  not  of  closing  it.  In  acute  conditions  these  methods  may  suc- 
ceed, but  where  the  fistulous  tract  is  surrounded  by  cicatricial  tissue, 
cauterization  will  be  more  likely  to  result  in  enlarging  the  orifice,  as  has 
been  pointed  out  by  Ziembicki.  If  the  stricture  is  in  the  deep  urethra, 
all  this  will  be  a  loss  of  time,  as  operation  on  the  fistula  involves  external 
urethrotomy  of  this  region,  and  this  will  overcome  the  stricture. 

Three  principal  surgical  methods  have  been  advised  and  attempted 
in  the  closure  of  these  fistulas.  The  first  consists  in  splitting  open  the 
peringeum,  urethra,  and  rectum  up  to  and  through  the  fistula,  thus 
forming  one  channel  for  the  escape  of  urine  and  f^cal  matters.  The 
fistulous  tract  is  then  curetted,  and  the  wound  left  to  heal  by  cica- 
trization. This  operation  has  been  done  a  number  of  times,  but,  so 
far  as  can  be  learned,  with  only  one  reported  success  (N.  Y.  Med.  Chir. 
Bull.,  1831,  vol.  ii,  p.  37). 

The  second  method  consists  in  splitting  the  recto-urethral  sasj^tum 
laterally  until  the  fistulous  tract  is  cut  across,  thus  converting  the 
condition  into  two  fistulas.  The  posterior  rectal  fistula  is  then  treated 
either  by  incision,  by  suturing  the  opening,  or  by  the  use  of  an  elastic 
ligature.  The  urethral  opening  is  left  in  this  method  to  heal  by  granu- 
lation, the  urine  passing  out  through  the  perineal  incision. 

Sir  Astley  Cooper's  method  is  a  modification  of  this,  and  consists 
in  splitting  the  recto-urethral  sgeptum  between  a  sound  in  the  urethra 
and  the  index  finger  of  the  left  hand  in  the  rectum  for  guides.  The 
division  is  carried  well  up  above  the  fistulous  tract,  dividing  the  latter 
into  two  portions.  The  wound  is  then  packed,  and  whatever  urine  es- 
capes through  the  urethral  opening  passes  out  into  the  dressing  or 
through  the  perineal  incision.  White  and  Martin  modify  this  method 
by  dissecting  out  and  suturing  the  urethral  and  rectal  openings  after 
splitting  the  peringeum. 


COMPLICATED  FISTULA  433 

The  operation  most  frequently  employed  consists  in  some  modifica- 
tion of  Sims's  operation  for  vesico-vaginal  fistula  upon  the  rectal  wall. 
It  is  much  more  difficult,  and  is  less  likely  to  succeed  in  these  cases  than 
in  the  variety  of  fistula  for  which  it  was  devised.  It  has  heen  attempted 
many  times,  but  no  more  than  3  cases  have  been  reported  in  which  it 
has  succeeded.  The  methods  of  Wyeth,  Kelsey,  and  Emmett  are  all 
modifications  of  this  method  and  open  to  the  same  objections.  It  has 
been  clearly  shown  that  the  passage  of  healthy  urine  over  a  sutured 
wound  does  not  materially  interfere  with  union.  It  is  necessary  to 
"  seek  for  some  other  cause,  therefore,  to  explain  the  numerous  failures 
by  the  suture  method.  When  the  urine  collects  in  a  pocket  it  decom- 
poses, pyogenic  bacteria  develop,  and  any  healthy  processes  in  the  part 
will  soon  be  checked."  The  fact  that  this  method  of  suturing  results 
in  a  depression  or  pocket  upon  the  urethral  side,  thus  causing  retention 
of  a  few  drops  of  urine,  easily  accounts  for  its  failures.  Especially  is 
this  true  in  cases  where  the  fistula  is  of  considerable  length  and  is  tor- 
tuous, for  in  such  the  tract  w  ould  be  only  partially  obliterated,  and  the 
urine  infected  with  whatever  bacteria  exist  in  the  urethral  or  bladder 
cavities  would  collect  in  the  remaining  portion  of  the  tract,  infect  the 
wound  and  prevent  union,  or  result  in  the  formation  of  a  second  fistula. 
The  ideal  operation  for  this  condition  consists  in  one  Avhich  will  immedi- 
ately close  the  fistula  without  leaving  any  such  pocket  or  unobliterated 
fistulous  tract  and  at  the  same  time  avoid  the  dangers  of  permanent 
fffical  incontinence. 

Ziembicki  (Cong.  Franc,  d.  Chir.  Proc.  Verb.,  1889,  vol.  iv,  p.  295) 
has  applied  a  new  principle  in  the  treatment  of  this  condition.  The 
operation  consists  in  dissecting  out  the  rectum  from  all  its  attachments 
up  to  a  point  somewhat  above  the  fistulous  orifice.  The  edges  of  the 
openings  in  both  rectum  and  urethra  are  then  freshened  and  sutured; 
finally,  the  free  end  of  the  rectum  is  rotated  upon  its  axis  until  the  open- 
ing in  this  organ  is  brought  well  off  to  the  side,  and  thus  out  of  line  with 
the  opening  in  the  urethra.  The  gut  is  held  in  this  position  by  sutures 
introduced  around  the  anal  margin.  The  idea  is  ingenious,  and  suc- 
ceeded in  the  case  reported,  notwithstanding  a  small  perineal  fistula 
formed  through  which  urine  escaped  for  a  short  time.  It  is  a  formi- 
dable operation,  however,  and  should  not  be  undertaken  except  by  a 
skilful  operator,  and  in  cases  in  which  less  extensive  dissections  have 
first  been  attempted.  Fuller  has  reported  a  successful  case  done  after 
this  method. 

The  combination  of  colotomy  with  suprapubic  drainage  of  the  blad- 
der has  been  employed  in  these  cases,  but  with  no  marked  success.  Even 
if  the  method  assured  a  cure  of  the  fistulous  tract,  it  would  not  be  justi- 
fied until  all  other  methods  had  failed.     The  dangers  of  cystitis  and 


434 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


frequent  failure  of  the  supra])ubie  openiug  to  close  after  drainage  has 
been  continued  for  a  long  time  contraindicate  this  procedure  under  all 
circumstances.  The  author's  observations  up  to  1896  had  been  limited, 
but  from  them  it  appeared  that  the  urethral  side  of  the  wound  always 
gave  way  first  in  suturing  operations,  and  resulted  in  the  reestablishment 
of  the  fistula.  Inasmuch  as  all  these  methods  formed  a  pocket  capable 
of  retaining  a  few  drops  of  urine  at  the  site  of  the  operation,  it  seemed 
that  if  this  could  be  prevented,  and  strain  on  the  sutured  surfaces 


(^A./Uf-^^'^-^. 


Flu.  157. — Rectim,  Perix.eu.m. 


J 

L  KETIIRA    INCISED    TO    LXl'u.-t    Kl-i   lu-U:l.THl;Ai.    ll.--Ul.A. 


avoided  until  union  had  taken  place,  the  question  of  curing  these  fistulas 
would  be  solved.  The  opportunity  to  test  this  otfered  itself  in  a  patient 
sent  to  the  clinic  by  Dr.  Bodine;  the  fistula  opened  into  the  rectum  about 
•|  an  inch  above  the  external  sphincter,  and  was  large  enough  to  admit 
the  tip  of  the  index  finger.  It  extended  upward  into  the  urethra  through 
a  tract  about  f  of  an  inch  in  length.  There  was  considerable  cicatricial 
deposit  about  the  opening,  and  a  stricture  of  the  membranous  urethra 
anterior  to  the  fistulous  opening.     The  pendulous  urethra  was  normal. 


COMPLICATED   FISTULA 


435 


The  patient  was  prepared  for  treatment  by  clearing  out  the  intestinal 
canal,  sterilization  of  the  urinary  tract  through  the  administration  of 
boric  acid  and  salol, 
and  daily  irrigations  of 
the  urethra  and  blad- 
der. 

On  August -SO,  1896, 
the  operation  was  per- 
formed as  follows:  The 
rectum  was  incised  in 
the  middle  line  anteri- 
orly, the  cut  being  car- 
ried through  into  the 
urethra  and  extended 
from  the  scrotal  junc- 
ture of  the  perinteum 
into  the  fistulous  open- 
ing, thus  dividing  the 
urethral  stricture  (Fig. 
157).  The  cicatricial 
tissue  around  the  en- 
tire fistula  was  trimmed 
away  with  scissors. 
The  intestinal  wall  was 
then  dissected  from  its 
anterior  attachments 
for  f  of  an  inch  above 
the  fistula,  and  ^  an 
inch  to  each  side;  a  flap  was  then  dissected  from  the  soft  tissues  on  either 
side  of  the  urethra  large  enough  to  replace  that  portion  of  the  floor  of 
this  organ  which  had  been  destroyed.  A  steel  sound  (ISTo.  30  French)  was 
introduced  into  the  bladder,  and  these  flaps  sutured  together  over  it  at 
a  slight  tension.  Secondary  flaps  were  taken  outside  of  the  first  flaps 
and  entirely  surrounding  them,  making  a  sort  of  cufl^  to  the  first  area 
sutured  (Fig.  158).  The  edges  of  the  rectal  wall  were  sewed  together  in 
all  their  thickness  with  chromicized  catgut  down  to  the  external  sphinc- 
ter muscle,  at  which  point  the  mucous  membrane  was  dissected  loose  for 
a  short  distance  to  each  side,  and  drawn  together  by  stitches  which  did 
not  involve  the  muscle.  The  incision  into  the  urethra  from  just  below 
the  site  of  the  fistulous  opening  was  left  unsutured  (Fig.  159).  A  ISTo.  12 
soft-rubber  catheter  introduced  through  the  meatus  into  the  bladder 
was  fastened  there  by  adhesive  straps  attached  to  the  head  of  the  penis. 
The  anterior  portion  of  the  perineal  incision  was  loosely  jaacked  with 


Fig.   158. — Kecto-itrethral   Fistula  and   Wound   in  the 

Kectum  closed. 
The  incision  in  the  urethra  anterior  to  the  fistula  is  left  open. 


436 


THE  ANUS,  RECTUM,   AND   PELVIC  COLON 


Fig.  159. 


absorbent  gauze,  and  a  large  sized  drainage-tube  introduced  into  the 
rectum  to  facilitate  the  escape  of  gas.  The  catheter  seemed  to  cause 
the  patient  no  inconvenience,  and  it  was  left  in  position  for  eighteen 

days,  the  bladder  and 
perineal  wound  being 
irrigated  daily  with 
Thiersch's  solution. 

The  patient,  after 
serving  as  an  assistant 
around  the  hospital  for 
several  weeks,  was  dis- 
charged December  1, 
1896,  perfectly  cured. 
He  presented  himself 
for  examination  in 
February,  1902,  and 
was  still  well.  The 
success  of  the  opera- 
tion is  ascribed  to  leav- 
ing no  pocket  at  the 
site  of  the  fistula,  ab- 
solutely free  drainage 
for  the  urine  through 
the  perina?um,  and  the  section  of  the  external  sphincter  muscle  which 
places  the  parts  at  rest  and  at  the  same  time  prevents  any  obstruction 
to  the  passage  of  gas  or  ivccal  matter. 

In  one  case  in  which  the  author  operated,  there  was  so  much  cica- 
tricial tissue  and  the  opening  into  the  urethra  was  so  extensive,  that  it 
was  impossible  to  obtain  sufficient  flaps  of  healthy  tissue  upon  the  sides 
to  restore  the  floor  of  this  organ.  In  that  case  both  ends  of  the  urethra 
were  dissected  loose  and  sutured  together  (Fig.  160),  thus  making  a 
practical  resection  of  the  urethra.  Over  this  it  was  possible  to  drag 
and  suture  a  very  thin  fold  dissected  from  the  peri-urethral  tissues. 
The  success  in  this  case  was  remarkable  from  the  beginning.  There 
was  never  a  drop  of  urine  passed  from  the  perineal  wound  so  far  as 
the  patient  was  aware.  The  rectal  wound  healed  by  primary  union, 
and  the  patient  left  the  hospital  completely  well  at  the  end  of  six 
weeks.  One  year  later,  however,  he  returned  to  the  workhouse,  hav- 
ing failed  to  keep  up  the  dilatation  of  the  urethra  by  the  passage 
of  sounds  as  directed,  and  was  found  to  be  suffering  from  a  stric- 
ture at  the  point  of  suture  in  the  uretlira.  By  gradual  dilatation 
his  symptoms  disappeared,  and  he  left  the  hospital  at  the  end  of 
three  months,  once  more  apparently  well.     This  was  eighteen  months 


-Final  Step  ix  Opeuation  kok  Kecto-irethral 
Fistula. 


COMPLIGATED  FISTULA 


437 


after  the  operation,  and  no  return  of  the  recto-iirethral  fistula  had 
occurred. 

Theoretically  it  is  important  to  retain  the  catheter  in  the  bladder 
seven  to  ten  days,  and  yet  in  those  cases,  three  in  number,  in  which  this 
was  impossible,  there  were  no  unfortunate  results.  If  it  once  slips  out 
there  is  danger  of  reperforating  the  rectum  in  attempting  to  reintroduce 
it  through  the  meatus.  This  accident  happened  in  a  case  operated  upon 
by  Percy  Bolton  after  this  method.  The  catheter,  instead  of  entering 
the  bladder,  perforated  the  sutured  wound,  and  extended  upward  in  the 
rectum  for  about  4  inches;  it  was  removed  at  once,  and  the  parts  left 
to  heal  by  granulation.  This  was  a  very  slow  process,  and  it  was  not 
completed  at  the  end  of  four  months  when  the  patient  left  for  home. 
Subsequently  it  was  reported  that  the  opening  into  the  rectum  com- 
pletely healed,  and  that  the  patient  only  suffered  from  a  slight  leak- 
age from  the  perineal 
wound  at  the  time  of 
urination.  The  cathe- 
ter in  such  instances 
should  be  reintroduced 
by  passing  it  from  the 
meatus  through  the 
perineal  wound,  and 
then  upward  and  back- 
ward against  the  supe- 
rior wall  of  the  urethra 
through  this  opening; 
in  this  way  it  can  be 
introduced  without  im- 
pinging upon  the  su- 
tured wound.  In  case 
the  patient  is  unable 
to  bear  the  irritation 
of  a  permanent  cathe- 
ter, the  urine  should 
be  drawn  every  three 
hours  by  a  skilful 
surgeon  with  a  well- 
curved  silver  catheter 
held  close  to  the  supe- 
rior wall  of  the  urethra  during  the  first  five  days.  It  is  important  that 
the  bladder  should  not  become  distended  and  urine  allowed  to  leak 
over  into  the  wound.  While  the  number  of  cases,  9  in  all,  is  very 
few,  they  are  sufficient  to  establish  the  fact  that  such  cases  can  be  cured. 


Fig.  160. — Eesectiox  of  the  Ukethra  fok  Eecto-ieethral 
Fistula. 


438  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

Recto-vesical  and  Entero-vesical  Fistulas. — The  two  conditions  indi- 
cated by  the  terms  here  used  differ  simply  with  regard  to  the  portion 
of  the  intestinal  canal  which  connects  with  the  bladder.  They  both 
consist  in  an  abnormal  communication  between  the  intestinal  tract  and 
the  urinary  viscus.  They  were  more  or  less  frequent  in  times  past  when 
it  was  the  practice  to  puncture  the  bladder  through  the  rectum  in  cases 
of  retention  of  urine.  This  having  become  obsolete,  fistulas  of  this 
variety  have  largely  disappeared.  They  do,  however,  occasionally  occur 
as  a  result  of  accidents  or  operations  upon  the  bladder  and  rectum  in 
the  course  of  malignant  disease,  and  through  the  process  of  destructive 
inflammation. 

Instances  of  wounds  connecting  the  bladder  with  the  rectum  are 
quite  numerous,  but  these  very  frequently  close  spontaneously  and  no 
fistula  results.  Thus,  in  the  chapter  u])on  accidents  and  injuries,  refer- 
ence is  made  to  a  number  of  cases  in  which  bullet  wounds  and  sharp, 
puncturing  instruments,  such  as  bars  of  iron  and  paling-sticks,  have 
passed  through  the  rectum  and  into  the  bladder,  and  yet  the  recto- 
vesical communications  have  closed  without  any  surgical  interference. 
Bartels  (Archiv  fiir  klin.  Chir.,  Berlin,  1878,  Bd.  xxii,  S.  519)  collected 
78  cases  of  wounds  of  the  bladder  in  which  only  5  resulted  in  fistula. 
It  is  only  after  the  communication  has  existed  for  a  certain  period  that 
it  should  be  recognized  as  a  fistula. 

The  Character  of  the  Fistula. — This  type  of  fistula  may  be  direct  or 
indirect.  In  the  first  instance  it  is  due  to  a  matting  together  and  direct 
perforation  of  the  intestinal  and  vesical  walls.  In  such  cases  the  tract 
is  very  short  and  the  openings  absolutely  opposite  each  other.  The 
mucous  membrane  of  one  organ,  as  cicatrization  occurs,  coalesces  with 
that  of  the  other,  and  a  mucous  tract  between  the  two  cavities  is  formed. 
This  may  occur  at  the  base  of  the  bladder  in  the  neighborhood  of  the 
trigone,  when  the  communication  will  be  with  the  rectum;  or  higher  up 
in  the  fundus,  when  it  will  be  with  the  sigmoid  flexure  or  small  intestine. 

The  tract  may  also  be  indirect,  owing  to  rupture  of  abscesses  into 
both  organs.  In  such  cases  the  openings  will  be  separated  by  the  abscess 
cavity.  Thus  the  fistulous  tract  will  be  more  or  less  elongated  and  very 
irregular  in  shape.  The  openings  may  or  may  not  be  opposite  each 
other;  in  all  probability  they  will  be  considerably  separated.  The  patho- 
logical cliaracters  of  these  fistulas  are  practically  the  same  as  those  of 
ano-rectal  fistulas;  they  may  be  inflammatory,  tubercular,  or  malignant. 
While  serious  in  all  cases,  the  degree  will,  of  course,  depend  upon  the 
pathological  cause. 

Etiolngy. — Traumatism  or  wounds  are  comparatively  frequent  causes. 
Velpeau  (ISTouveaux  elem.  de  med.  o])er.,  Paris,  1839,  t.  iv,  p.  564)  esti- 
mated that  20  per  cent  of  them  result  from  recto-vesical  wounds.    There 


COMPLICATED   FISTULA  439 

are  no  statistics  at  the  present  day  to  establish  or  to  deny  these  facts, 
but  inasmuch  as  all  operations  upon  the  bladder  through  the  rectum 
have  been  relegated  to  the  surgery  of  the  past,  it  is  probable  that  the 
percentage  from  these  causes  has  been  materially  reduced.  Dittel 
(Wiener  med.  Woch.,  1881,  Bd.  xxxi,  S.  261,  293,  and  321)  relates  1  case 
in  which  the  fistula  was  produced  by  violent  catheterization. 

In  one  instance  of  carcinoma  of  the  bladder,  the  sounding  of  this 
organ  with  a  Thompson  searcher  produced  a  communication  between 
the  two  cavities — at  least  the  discharge  of  urine  into  the  rectum  and 
faeces  into  the  bladder  had  not  been  observed  until  after  this  examina- 
tion; but  that  any  surgeon  should  be  violent  and  careless  enough  to 
penetrate  a  healthy  vesico-rectal  ssejatum  in  sounding  the  bladder  is 
incredible. 

In  gunshot  injuries  and  puncturing  wounds  the  fistula  does  not 
always  appear  immediately  after  the  injury,  but  it  may  follow  some  days 
or  weeks  later,  owing  to  sloughing  around  the  edges  of  the  wound,  as  is 
stated  by  Bartels,  or  to  an  extravasation  of  urine  into  the  sgeptum  be- 
tween the  two  cavities,  and  subsequent  rupture  of  the  abscess. 

Wounds  due  to  foreign  bodies  in  the  rectum,  as  pins,  needles,  fish- 
bones, rectal  concretions,  etc.,  may  result  in  a  perforation  of  the  sseptum 
between  the  two  organs,  and  stone  in  the  bladder  has  been  observed  by 
Herczel  (Beitrage  zurklin.  Chir.,  Tubingen,  1889,  Bd.  v,  S.  690)  to  result 
in  a  recto-vesical  fistula. 

Inflammatory  conditions  both  of  the  bladder  and  the  rectum  are 
accountable  for  the  large  majority  of  such  fistulas  at  the  present  day. 
Catarrhal  inflammation  of  the  bladder  (Mercier,  Gaz.  med.,  1836,  pp. 
257,  273;  and  Ballance,  Lancet,  London,  1883,  t.  i,  pp.  411,  485),  dysen- 
tery (Herczel,  he.  cit.),  typhoid  fever  (Woodward,  Med.  and  Surg. 
Hist,  of  War  of  the  Eebellion),  appendicitis,  and  tubercular  ulceration 
of  both  bladder  and  intestine  have  been  known  to  result  in  this  con- 
dition. 

Prostatic  disease,  either  suppurative  or  tubercular,  may  result  in 
recto-vesical  fistula  through  the  formation  of  an  abscess  between  the 
tunics  of  the  two  organs,  which  abscess  ruptures  first  into  one  and  then 
into  the  other  viscus,  thus  forming  the  indirect  variety  of  fistula  which 
was  mentioned. 

Diverticuli  in  the  walls  of  the  bladder  or  rectum  may  enclose  small 
calculi  or  fsecal  concretions,  which  result  in  inflammation,  adhesion  be- 
tween the  walls  of  the  two  organs,  subsequent  perforation,  and  fistula. 
Malignant  disease  is  one  of  the  several  causes  of  this  condition,  and 
may  proceed  from  either  organ.  This  occurs  largely  in  men,  owing  to 
the  close  relationship  between  the  bladder  and  the  rectum;  but  it  is 
not  unknown  in  women  as  a  result  of  extensive  pelvic  and  peri-uterine 


440 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


inflamiiiatioiis;  in  these  the  communications  occur  between  the  sigmoid 
flexure  or  small  intestine  and  the  bladder. 

The  author  has  seen  2  cases,  however,  in  which  the  bladder  com- 
municated with  the  rectum  through  fistulous  tracts  that  passed  around 
the  cervix  just  above  the  vaginal  wall  (Fig.  161).    One  of  these  patients 

was  the  victim  of  constitution- 
al syphilis;  in  the  other  it  was 
impossible  to  account  for  the 
condition. 

In  tliat  portion  of  the  intes- 
tinal tract  in  close  apposition 
with  the  bladder  walls,  tuber- 
culosis may  no  doubt  result  in 
ulceration,  perforation,  and  the 
formation  of  fistula,  but  it  is 
rarely  the  cause  of  such  a  com- 
munication between  the  blad- 
der and  the  movable  portions 
of  the  intestinal  canal,  as  ad- 
hesive peritonitis  is  not  a  fre- 
quent complication  of  tubercu- 
lar ulceration  of  the  intestine, 
and  it  is  absolutely  necessary 
to  the  formation  of  an  entero- 
vesical  fistula.  The  recognition 
of  the  pathological  causes  of  this  condition  is  of  the  utmost  importance, 
as  upon  it  will  depend  the  advisability  of  radical  interference.  It  is  also 
important  to  know  whether  the  rectum,  the  sigmoid  flexure,  or  the  small 
intestine  communicates  with  the  bladder,  as  the  prognosis  differs  in  all 
these  cases. 

Cripps  (The  Passage  of  Air  and  Fa?ces  from  the  Urethra,  London, 
1888)  has  collected  63  cases  of  entero-vesical  fistula  in  which  the  intes- 
tinal opening  was  twenty-five  times  in  the  rectum,  fifteen  times  in  the 
sigmoid  flexure,  twelve  times  in  the  small  intestine,  and  five  times  in 
both  the  small  intestine  and  colon. 

In  the  18  cases  collected  by  Quenu  and  Hartmann.  the  opening  was 
nine  times  in  the  rectum,  four  times  in  the  sigmoid  flexure,  twice  in 
the  small  intestine,  twice  in  the  vermiform  appendix,  and  once  in  the 
ca?cum. 

From  other  sources  8  cases  have  been  collected  in  which  the  opening 
Avas  four  times  in  the  rectum,  twice  in  the  sigmoid  flexure,  once  in  the 
small  intestine,  and  once  in  the  vermiform  appendix. 

So  there  are  89  cases  in  which  the  opening  was  in  the  rectum  in 


Fift.  161. — Eecto-vesico-vaginal  Fistula. 


The  fistulous  tract  indicated  by  the  dotted  line 
passed  around  the  cervix  and  not  through  it. 


COMPLICATED   FISTULA  441 

38,  sliowing  that  this  is  tlie  most  frequent  site.  A  fact  which  sliould 
be  remembered  is,  that  while  a  stone  may  exist  in  tlie  bladder  in 
these  cases,  it  is  not  necessarily  the  cause  of  fistula,  but  may  be  the 
result  of  the  same  through  some  of  the  fsecal  contents  escaping  into  the 
organ  and  thus  forming  a  nucleus  around  which  the  stone  forms.  Thus, 
for  instance,  in  the  case  reported  by  Kelsey,  a  stone  which  was  supposed 
to  have  caused  a  fistula  proved  to  be  the  accumulation  of  urates  about 
the  broken  end  of  a  catheter  which  had  been  introduced  with  a  view 
of  curing  the  fistula. 

Symptoms  and  Diagnosis. — The  characteristic  symptoms  of  recto- 
vesical fistula  are  the  presence  of  urine  in  the  rectum  with  or  without 
the  presence  of  fa?cal  materials  and  gas  in  the  bladder.  The  communi- 
cation between  the  two  organs  may  be  sufficiently  large,  or  the  tract 
may  be  in  such  a  direction  that  urine  can  escape  from  the  bladder  into 
the  reetum  and  fa?cal  matter  can  not  escape  from  the  rectum  into  the 
bladder.  The  presence  of  gases  in  the  bladder  should  not  be  taken  as 
a  pathognomonic  evidence  of  entero-vesical  fistula;  it  is  well  known  that 
these  may  develop,  owing  to  certain  chemical  changes  in  the  urine,  and 
be  expelled  during  the  passage  of  the  last  few  drops  of  this  secretion. 
Dittel,  Hartmann,  and  Blanquinque  have  all  reported  cases  of  this  kind, 
which  may  be  termed  essential  gas  formation  in  the  bladder.  While, 
therefore,  there  may  be  entero-vesical  fistulas  without  gas  or  fsjcal  mat- 
ter in  the  urine  they  almost  never  occur  without  the  escape  of  urine 
into  the  rectum.  The  constant  presence  of  urine  in  the  rectum,  how- 
ever, does  not  necessitate  a  persistent  dribbling  from  the  anus.  A  cer- 
tain number  of  cases  have  been  observed  in  which  the  patients  were' 
able  to  control  the  urine  after  it  had  escaped  into  the  rectum  (E.  ]\Ionod, 
Diet,  encyc.  des  sci.  med.,  and  P.  Blanquinque,  These  de  Paris,  1870, 
p.  169). 

The  character  of  the  fjecal  discharge  into  the  bladder,  and  subse- 
quently passed  out  through  the  urethra,  varies  according  to  the  digestive 
functions  of  the  patient  and  the  size  of  the  aperture  between  the  two 
organs.  Small  pieces  of  meat,  fibrous  portions  of  vegetables,  bone,  fat, 
and  fruit  seeds  have  all  been  found  in  the  bladder  and  passed  through 
the  urethra  after  much  straining  and  pain.  The  nature  of  these  ma- 
terials has  been  said  to  throw  some  light  upon  the  site  of  the  intestinal 
opening;  but  this  is  denied  by  the  best  observers,  who  state  that  solid 
substances  have  been  passed  when  the  fistulous  opening  was  in  the  small 
intestine  as  well  as  when  it  was  in  the  rectum;  and  liquid  substances 
are  passed  in  both  instances. 

The  diagnosis,  therefore,  depends  chiefly  upon  the  presence  of  urine 
in  the  rectum;  not  only  must  the  urine  escape  into  the  rectum,  but  it 
must  be  constantly  present  and  not  alone  at  the  periods  of  micturition. 


442  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

WTiere  the  commimication  exists  between  the  bladder  and  some  portion 
of  the  intestine  high  up,  it  may  be  dilficult  to  determine  the  constant 
presence  of  urine  in  the  rectum,  inasmuch  as  the  fluid  then  becomes 
mixed  with  the  intestinal  contents.  However,  in  such  cases  there  will 
usually  be  the  corroborating  evidence  of  gas  and  fa?cal  matters  in  the 
bladder. 

The  history  of  the  case  will  always  have  some  bearing  upon  the  diag- 
nosis, but  this  is  generally  meager.  Cystitis  or  proctitis  and  the  passage 
of  lumpy  or  dark-colored  urine  may  have  been  observed,  but  more 
frequently  the  symptoms  first  complained  of  will  be  diarrhoea,  or  rather 
a  constant  desire  to  defecate,  which  results  only  in  the  passage  of  a 
small  quantity  of  clear  water.  Pus  and  blood  may  be  contained  in 
the  discharges,  especially  if  the  fistula  be  the  result  of  a  pelvi-rectal 
abscess.  In  such  cases  the  history  of  abscess  with  its  rupture  and  dis- 
charge of  pus,  either  by  the  urethra  or  the  anus,  can  be  clearly  elicited. 
In  tubercular  cases  the  general  physiognomy  and  constitutional  con- 
dition will  indicate  the  nature  of  the  disease  to  a  certain  extent,  but 
not  invariably.  In  malignant  disease  the  history  of  pain,  diarrhoea, 
frequent  micturition,  loss  of  flesh,  and  general  cachexia  will  corroborate 
the  evidences  which  may  be  obtained  by  the  speculum  and  by  digital  and 
cystoscopic  examinations. 

The  differential  diagnosis  between  recto-urethral  and  recto-vesical 
fistula  will  be  found  in  the  preceding  section. 

Having  determined  the  existence  of  a  connection  between  the  blad- 
der and  the  intestinal  tract,  the  next  step  in  diagnosis  is  to  learn  the 
site  of  the  intestinal  opening.  If  it  is  low  down  at  the  trigone  of  the 
bladder,  just  above  the  prostate,  it  may  be  made  out  by  digital  touch; 
if,  however,  the  opening  is  small  and  is  ensconced  between  the  folds 
of  mucous  membrane,  it  may  sometimes  escape  notice.  Moreover,  if 
it  occur  more  than  4  inches  from  the  anal  orifice  it  will  be  practically 
impossible  to  make  a  diagnosis  in  this  way.  The  use  of  the  pneumatic 
sigmoidoscope  is  of  great  assistance  in  such  cases.  Not  only  may  open- 
ings into  the  rectvmi  be  detected,  but  also  those  into  the  sigmoid  flexure 
— something  which  was  impossible  except  by  uncertain  inferences  until 
this  instrument  was  devised. 

The  cystoscope  is  of  advantage  to  demonstrate  an  opening  into  the 
bladder,  but  unfortunately  it  gives  no  information  as  to  the  point  of 
the  intestinal  tract  with  which  it  communicates.  ]\Ioreover,  if  the  open- 
ing be  of  any  considerable  size  it  will  be  difficult  to  distend  the  bladder 
sufiiciently  to  operate  this  instrument  properly. 

By  the  aid  of  a  long,  flexible  probe  through  the  proctoscope,  one 
may  determine  the  course  of  the  fistula,  and  a  view  of  the  parts  will 
indicate  the  pathological  nature  to  a  certain  degree.     The  dangers  of 


COMPLICATED   FISTULA  443 

tearing  loose  the  adhesions  between  the  two  organs  and  thus  opening 
the  peritoneal  cavity,  should  always  be  borne  in  mind  when  using  the 
probe. 

The  practice  of  injecting  colored  fluids  into  the  bladder,  in  order 
to  determine  if  there  is  a  communication  between  this  organ  and  the 
rectum,  is  practically  useless  as  a  diagnostic  measure.  Dumesnil  has 
advised  the  injection  of  a  very  weak  solution  of  perchloride  of  iron  into 
the  bladder  while  at  the  same  time  he  introduced  a  sponge  into  the 
rectum  soaked  in  a  solution  of  yellow  prussiate  of  potash  (1  to  500);  the 
combination  of  the  two  solutions  produces  a  chemical  reaction  which 
demonstrated  to  his  mind  the  existence  of  a  communication  between  the 
two  organs.  This  chemical  reaction  must  take  place  immediately,  or 
it  may  be  assumed  that  it  might  occur  through  osmotic  or  circulatory 
channels.  Thus,  if  the  fistula  is  high  up  in  the  intestinal  tract,  the 
length  of  time  which  will  elapse  before  the  fluid  from  the  bladder  could 
come  in  contact  with  the  sponge  below  would  necessarily  invalidate  the 
importance  of  the  chemical  reaction  obtained.  The  presence  of  uric- 
acid  crystals  in  the  fsecal  discharges,  and  the  reaction  obtained  from  this 
substance,  will  be  better  evidence  of  the  existence  of  urine  in  the  rectum 
than  can  be  possibly  obtained  by  the  injection  of  colored  fluids  into 
either  organ. 

Prognosis. — The  prognosis  in  these  conditions  is  always  grave. 
Wliile  there  is  a  certain  number  of  cases  which  have  resulted  in  spon- 
taneous cure,  the  hope  of  such  a  termination  is  most  illusory. 

The  results  of  surgical  interference  are  scarcely  more  encouraging. 
Cripps  estimated  that  the  average  length  of  life  in  this  condition  is 
something  less  than  two  years,  although  there  is  one  case  reported  which 
lived  as  long  as  thirty  years  after  the  fistula  developed.  Blanquinque 
has  summarized  the  results  of  operative  treatment  in  30  cases  as  follows: 
Pour  cured,  5  unimproved;  3  deaths  from  other  diseases;  4  deaths  in 
which  particulars  were  not  given,  and  15  from  urinary  infiltration,  peri- 
tonitis, exhaustion,  suppuration  and  infiammation  of  the  rectum  and 
bladder  (Quenu  and  Hartmann,  op.  cit.,  p.  238).  In  this  enumeration 
of  the  causes  of  death,  the  extension  of  the  inflammatory  condition 
from  the  bladder  upward  through  the  ureter  to  the  kidney  seems  to 
have  been  omitted.  The  majority  of  observers  refer  to  this  as  the 
most  serious  complication,  and  it  is  probably  the  most  frequent  cause 
of  death  in  these  cases.  The  cystitis  and  proctitis,  while  annoying 
and  irritating,  are  not  of  such  a  grave  nature  as  to  bring  about  a 
fatal  termination  in  themselves.  In  the  majority  of  instances  the  rectum 
becomes  tolerant  after  a  time  to  the  presence  of  urine;  and  while  this 
does  produce  a  chronic  catarrhal  inflammation  of  the  organ,  it  is  rarely 
of  serious  import.     The  dangers  are  therefore  upon  the  side  of  the 


444  THE  AXUS,  RECTUM,   AND   PELVIC  COLON 

bladder,  ureters,  and  kidneys  in  cases  of  direct  fistula.  In  the  indirect 
variet}',  where  there  is  an  abscess  cavity  between  the  two  openings,  the 
accumulation  of  urine  and  faecal  matters  in  this  is  likely  to  result  in 
urinary  infiltration  or  burrowing  tracts  which  may  perforate  the  peri- 
tona-um,  extend  down  to  the  buttocks  or  around  the  anus,  causing  fatal 
peritonitis  or  eventuating  in  lardaceous  changes  of  the  glandular  organs, 
exhaustion,  and  death. 

Treatment. — In  the  treatment  of  this  condition  it  is  more  important 
to  prevent  the  escape  of  fa?cal  matter  into  the  bladder  than  that  of  urine 
into  the  rectum.  Permanent  or  periodical  catheterization  and  irrigation 
of  the  bladder  have  failed,  so  far  as  can  be  learned,  to  produce  a  single 
cure.  In  acute  conditions  due  to  accidents,  injuries,  or  surgical  proced- 
ures, permanent  catheterization,  together  with  constipation  of  the  bow- 
els, may  facilitate  the  healing.  Certain  positions,  such  as  laying  the  pa- 
tient upon  his  face  or  side,  so  that  the  secreted  urine  will  gravitate  in  the 
opposite  direction  from  the  wound,  may  also  be  of  benefit;  but,  unless 
faecal  material  is  kept  out  of  the  bladder,  these  procedures  will  be  of 
little  use.  "Where  a  fistula  is  once  established  the  surgeon  is  brought 
face  to  face  with  one  of  two  procedures:  either  a  direct  closure  of  the 
fistulous  tract  itself  or  the  diversion  of  the  f»cal  current. 

Diversion  of  the  Fcccal  Current. — "Where  the  opening  is  in  the  rec- 
tum or  lower  portion  of  the  sigmoid,  a  temporary  artificial  anus  may, 
together  with  permanent  catheterization,  result  in  the  closure  of  the 
ftecal  fistula.  At  any  rate,  such  a  diversion  of  the  fa?cal  current  will 
contribute  largely  to  the  probabilities  of  successfully  suturing  the  fistula. 

Quenu  and  Hartmann  advise  making  a  permanent  artificial  anus  at 
once  in  these  cases,  but  such  a  radical  procedure  can  not  be  indorsed. 
The  temporary  anus  can  be  made  just  as  effectual  to  protect  the  parts, 
and  it  can  be  changed  into  the  permanent  form  at  any  time  if  desirable. 
Moreover,  it  can  be  closed  without  any  particular  danger  to  the  patient, 
provided  the  fistula  heals. 

The  question  of  temporary  artificial  anus,  the  methods  of  making  it, 
and  its  final  closure  will  be  found  in  the  chapter  on  Colostomy.  WTiere 
the  communication  between  the  bladder  and  the  intestine  is  above  the 
sigmoid  flexure,  an  artificial  anus  is  not  likely  to  prove  satisfactory, 
especially  if  it  must  be  made  in  the  small  intestine.  Here  one  should 
open  the  abdomen,  separate  the  two  organs,  and  close  the  fistulous  open- 
ings, as  will  be  described  later. 

After  the  fa^-al  current  has  been  turned  aside,  one  may  attempt  to 
close  the  recto-vesical  opening  by  freshening  the  edges  and  suturing  the 
wound,  just  as  in  the  operation  for  vesico-vaginal  fistula.  If  it  is  high 
up,  the  difficulties  of  approaching  it  may  be  overcome  by  the  removal 
of  the  coccyx  and  incision  of  the  posterior  wall  of  the  rectum.     Some 


COMPLICATED  FISTULA  445 

attempts  have  been  made  to  close  these  tracts  by  suprapubic  cystotomy 
and  suture  of  the  wound  from  the  vesical  surface.  No  case,  however, 
has  been  reported  as  cured  by  this  method  (Thompson;  Le-Dentu). 

It  has  also  been  proposed,  where  the  opening  is  low  down,  that  the 
anterior  wall  of  the  rectum  be  dissected  from  the  bladder  by  lateral  peri- 
neal section  to  a  point  above  the  fistulous  tract,  thus  cutting  the  latter 
in  two  and  converting  it  into  a  recto-perineal  and  vesico-perineal  fistula. 
If  within  reach  the  openings  may  be  sutured  from  the  perineal  wound; 
if  not,  this  may  be  packed  after  having  curetted  the  fistulous  openings. 
Where  the  fistula  results  from  a  pelvi-rectal  abscess,  unquestionably  this 
would  be  the  proper  procedure,  because  it  would  furnish  complete  drain- 
age to  the  abscess  cavity,  and  any  burrowing  tracts  could  be  laid  open  at 
the  same  time.  The  records  show  that  suture  of  fistula  from  the  rectal 
surface  has  proved  more  successful  in  these  cases  than  any  other  pro- 
cedure. In  the  statistics  of  Monod  (Diet,  des  scs.  med.,  vol.  i,  p.  437) 
and  Dumesnil  (Revue  de  chir.,  1884,  p.  24),  26  cases  are  collected  in 
which  artificial  ani  were  made  for  the  cure  of  recto-vesical  fistulas  with- 
out a  single  success.  Amelioration  resulted  in  some,  and  in  two  life 
was  prolonged  five  and  six  years.  According  to  Brant,  Dumesnil,  and 
Herezel,  this  operation  should  be  reserved  for  fistulas  due  to  malignant 
growths.  The  author  can  not  go  so  far  as  this,  but  would  advise  that 
the  temporary  artificial  anus  be  employed  in  these  cases  as  a  preliminary 
to  suturing  the  fistula  from  the  rectal  side.  The  diversion  of  the  fsecal 
current  is  important  for  this  purpose,  but  it  is  not  curative. 

In  suturing  the  fistula,  Czerny's  method  of  employing  catgut  for  the 
deep  row,  and  silk  or  silkworm  gut  in  the  mucous  membrane,  appears 
the  most  rational.  The  superficial  sutures  should  be  removed  at  the 
end  of  the  seventh  day. 

Where  the  fistulous  opening  is  in  the  sigmoid  fiexure,  or  connected 
with  some  higher  portion  of  the  intestinal  canal,  a  more  radical  operation 
through  abdominal  incision  will  be  called  for.  In  such  cases  it  will  be 
necessary  to  open  the  abdominal  cavity,  separate  the  adhesions  between 
the  bladder  and  the  intestine,  and  then  suture  the  openings  separately. 
Where  the  adhesion  is  extensive  and  the  peritoneal  covering  of  the 
intestine  has  been  destroyed  by  inflammatory  processes,  simply  suturing 
the  opening  is  not  likely  to  close  it.  In  such  cases  it  is  better  to  resect 
the  portion  of  the  intestine  involved.  The  wound  in  the  bladder  may 
then  be  sutured  by  folding  in  the  walls  after  the  manner  of  Lembert. 

Having  accomplished  the  closure  of  the  openings,  a  gauze  wick,  sur- 
rounded by  protective  tissue,  should  be  passed  down  to  the  opening  in 
the  bladder  and  left  there  for  several  days.  Where  the  intestinal  opening 
has  been  sutured  without  resection,  a  second  wick  should  be  carried  down 
and  held  in  apposition  with  this  suture,  but  the  space  between  the  two 


44:6        THE  AXUS,  RECTUM,  AND  PELVIC  COLON 

openings  should  bo  widened  by  a  ^Mikulicz  drain  in  order  tliat  the  leak- 
age from  one  cavity  shall  not  affect  the  other.  Terrier  has  adopted 
this  method  without  suturing  either  opening,  but  simply  placing  a  drain 
between  the  bladder  and  intestine;  in  his  case  the  cure  of  the  vesical 
opening  appeared  to  be  immediate,  and  the  fa?cal  fistula  which  resulted 
healed  in  a  short  time.  Skene  has  also  used  this  method  with  success 
in  one  case  (personal  communication),  but  the  combination  of  suturing 
and  draining  afterward  would  appear  to  promise  the  best  results. 

Recto-ureteral  Fistula. — A  certain  number  of  cases  of  ureteral  fistula 
have  been  reported,  but  none  in  which  the  opening  was  into  the  rectum 
itself,  except  in  malformations  which  have  been  already  described  in  the 
cliapter  upon  that  subject.  Kelly,  Kuster,  Tufher,  Morestin,  and  others 
have  attempted  the  transplantation  of  ureters  into  the  rectum  in  cases 
of  extirpation  of  tlie  bladder  for  malignant  disease.  These  cases,  how- 
ever, have  been  experimental,  and  have  no  practical  bearing  upon  recto- 
ureteral  fistula.  In  one  case  reported  by  Bayard  a  communication  be- 
tween the  ureter  and  the  duodenum  was  found. 

Simon  has  attempted  the  total  extirpation  of  the  bladder  for  car- 
cinoma, and  planting  tlie  ureters  in  the  rectum.  His  patient,  however, 
died  of  peritonitis.  The  author  has  seen  one  case  in  which  a  recto- 
vagino-ureteral  fistula  resulted  from  an  operation  for  the  extirpation 
of  a  carcinomatous  uterus,  and,  strange  as  it  may  appear,  the  fistula 
closed  spontaneously. 

Recto-genital  Fistula. — The  terra  recto-genital  is  applied  to  all  those 
abnormal  openings  occiirring  between  the  rectum  and  the  genital  organs, 
as  distinguished  from  the  urinary.  The}^  are  practically  confined  to  the 
female  sex,  and  should  not  embrace  those  communications  due  to  mal- 
formations. A  perineal  fistula,  extending  forward  and  into  the  scrotum, 
may  be  termed  a  recto-genital  fistula,  but  as  it  has  no  peculiar  charac- 
teristics differing  from  the  ordinary  subtegumpntary  fistula,  it  need  not 
be  discussed  in  this  connection.  A  prostatic  abscess,  or  an  abscess  that 
occurs  as  a  result  of  suppuration  in  Cowper's  glands,  may  break  through 
into  the  rectum  without  communicating  with  the  urinary  tracts;  in  such 
cases  they  form  blind  internal  fistulas,  wliich  have  been  described.  As 
a  rule,  both  of  these  types  either  communicate  with  the  urinary  tracts 
in  the  beginning  or  later  in  their  course.  The  recto-genital  fistulas 
may  then  be  described  as  recto-uterine,  recto-vulvar,  and  recto-vaginal. 

Recto-uterine  fistulas  are  exceedingly  rare,  if,  indeed,  they  exist  at 
all  except  as  congenital  malformations.  Petit  (Annales  de  gynecol., 
Paris,  1882,  t.  ii,  p.  401,  and  1883,  t.  i,  pp.  14,  90,  290,  353,  431)  has 
thoroughly  reviewed  the  subject  of  entero-uterine  fistulas.  Xo  case  was 
noted  in  which  the  rectum  was  involved.  The  wiiter  has  seen  one  case 
in  which  a  carcinoma  uteri  involved  the  posterior  uterine  wall,  extended 


COMPLICATED  FISTULA  447 

to  the  rectum  and  produced  a  communication  between  the  two  organs 
through  which  a  uterine  sound  could  be  passed;  this  was  in  an  old 
woman  in  the  Almshouse  Hospital,  in  whom  curettage  of  the  carcinom- 
atous growth  had  been  practised  some  months  previously.  Whether 
the  neoplasm  produced  the  fistula,  or  whether  the  opening  was  made 
by  the  curettage,  it  is  impossible  to  say. 

It  is  possible  that  a  pelvi-rectal  abscess  originating  in  the  peri- 
uterine structure  might  eventually  break  through  into  both  organs; 
but  the  uterine  tissue  being  so  tough  and  resisting,  it  is  hardly  reason- 
able to  suppose  that  the  burrowing  would  extend  through  it  when  so 
many  lines  of  less  resistance  exist  about  it.  Musilier  (Bull,  de  la  soc. 
anat.,  Paris,  1874,  p.  848)  has  reported  a  case  of  a  woman  who  died 
from  albuminuria,  in  whom  the  necropsy  revealed  a  communica- 
tion between  the  pus  sac  in  a  uterine  fibroid  and  the  rectum.  There 
does  not  appear  to  have  been  any  communication  between  the  uterine 
and  rectal  cavities.  In  the  case  reported  by  Lauers  and  Bidder  (Eevue 
de  chir.,  Paris,  1885,  p.  1013,  and  Annales  de  gynecol.,  Paris,  1892,  t. 
ii,  Pi  118)  a  true  fistula  between  the  sigmoid  flexure  and  the  cavity  of 
the  uterus  has  been  established.  Quenu  and  Hartmann  report  a  similar 
<3ase  {op.  cit.,  214)  Avhich  healed  spontaneously,  and  the  authors  were 
not  able  to  state  what  portion  of  the  intestine  it  was  which  communi- 
cated with  the  uterus,  though  it  was  above  the  rectum. 

Prom  these  observations  one  gains  no  practical  information.  The 
fistula  is  a  possibility,  but  is  so  exceedingly  rare  that  operative  interven- 
tion to  cure  it  has  never  been  undertaken.  In  the  one  definite  case 
which  the  writer  saw  the  malignant  neoplasm  was  inoperable,  although 
the  patient  lived  some  four  months  after  the  fistula  appeared. 

Becto-vulvar  Fistula. — Fistulas  opening  in  the  genital  tract  anterior 
to  the  hymen  are  termed  recto-vulvar.  They  occur  ordinarily  as  a  result 
of  injury,  infection,  inflammation,  and  suppuration  of  the  glands  of  the 
labia  and  vagina  anterior  to  the  fourchette.  They  may  be  due  to  injuries 
during  labor  and  efforts  at  repair  of  the  perinseum.  Spencer  Wells 
(Med.  Times  and  Gaz.,  1860,  p.  61)  and  Barton  Hirst  (y^ni.  Journal  of 
Obstetrics,  1886,  p.  83)  have  reported  cases  due  to  violent  coitus.  Kelsey 
{op.  cit.,  p.  135)  reports  a  very  interesting  case  of  this  kind  in  which 
there  were  two  openings  in  the  vulva  and  two  in  the  rectum.  This  case, 
however,  originated  from  suppuration  in  the  labial  glands  upon  each 
side. 

Symptoms. — The  disease  ordinarily  begins  as  a  pimple  or  slight  in- 
flammation in  the  labia  of  one  side.  It  sometimes  occurs  simultane- 
ously on  both  sides.  If  this  is  not  opened  promptly  and  drained,  it  may 
burrow  backward  to  one  side  of  the  perineal  rhaphe  and  open  into  the 
anus.     It  may  also  burrow  into  the  ischio-rectal  fossa  after  it  passes  the 


448  THE  ANUS,  RECTUM,  AND  PEL\aC  COLON 

transversiis  perinei  muscles,  but  such  is  very  rarely  the  case.  The  tracts 
usually  run  directly  backward  beneath  the  superficial  perineal  fascia, 
and  open  either  into  the  anus  or  about  its  margin  in  the  anterior  quad- 
rant of  the  same  side  upon  which  the  labial  abscess  occurs. 

The  openings  may  be  single  or  multiple.  The  writer  has  seen  a  case 
in  which  there  were  four  openings  about  the  anus  and  one  just  within 
the  vulva.  The  patient  will  give  the  history  of  pain,  especially  upon 
walking,  a  swelling  about  the  genital  organs,  sometimes  difficulty  in 
micturition,  and  always,  if  the  fistula  is  incomplete,  of  a  sudden  relief 
from  these  pains  following  a  discharge  of  pus. 

The  opening  is  nearly  always  found  in  one  labia  or  the  other,  or  just 
within  the  vulva  in  front  of  the  hymen. 

Treatment. — The  treatment  of  these  cases  should  not  be  carelessly 
undertaken.  Great  care  should  be  observed  to  preserve  the  perineal 
body.  Open  incisions,  such  as  those  practised  upon  simple  ano-rectal 
fistulas,  may  result  in  disastrous  consequences  through  the  destruction 
of  the  female  perineum.  Taylor  advised  passing  a  probe  into  the  fis- 
tulous tract  from  the  vulvar  orifice  and  cutting  down  upon  it  at  a  point 
near  the  anal  margin,  thus  converting  the  condition  into  ano-rectal  and 
vulvo-perineal  fistulas.  The  rectal  portion  of  the  tract  he  treated  by 
the  ligature,  and  the  anterior  portion  by  stimulating  applications. 

In  the  light  of  modern  experience  with  excision  and  immediate  suture 
of  fistula,  it  appears  best  that  such  uncomplicated  tracts  should  alwa3's 
be  dissected  out  and  the  wounds  immediately  closed.  Where  there  are 
two  distinct  fistulous  tracts  which  communicate  with  each  other  in  the 
rectum,  as  in  the  case  described  by  Kelsey,  the  ingenuity  of  the  operator 
will  be  exercised  as  to  what  course  to  pursue.  It  seems  that  in  such 
cases  one  might  with  safety  excise  and  suture  the  two  perineal  tracts  at 
different  sittings,  or  if  there  be  only  a  slight  dissection  of  the  tissues, 
they  might  both  be  done  at  one  time. 

The  question  as  to  the  pathological  nature  of  these  fistulas  and  its 
infiuence  upon  the  operation  differs  in  no  wise  from  that  in  general  ano- 
rectal fistula.  If  the  process  be  tubercular,  the  fistula  should  be  entirely 
excised  and  the  edges  sutured  together;  or  else  it  may  be  treated  by  anti- 
septic irrigation  and  the  application  of  methylene  blue,  carbolic  acid, 
and  iodine,  or  with  pure  carbolic  acid  alone. 

Occasionally  these  fistulas  have  only  one  opening,  and  that  in  the 
rectum,  thus  forming  blind  internal  fistulas.  In  such  cases  the  fistula 
should  be  converted  into  a  complete  one,  and  if  it  fails  to  close  after 
injections  of  nitrate  of  silver  it  should  then  be  excised.  In  suturing  a 
wound  made  after  excising  these  fistulas,  it  is  very  important  that  ac- 
curate apposition  of  the  muscular  tissues  should  be  made.  In  order  to 
accomplish  this  one  should  in  cutting  down  upon  the  fistulous  tract 


COMPLICATED  FISTULA  449 

isolate  the  ends  of  the  nmscle  wlien  cut,  grasp  them  with  fixation  for- 
ceps, and  hold  them  to  one  side  while  the  fistula  is  dissected  out.  After 
the  deeper  portion  of  the  tract  has  been  closed  then  these  ends  should 
be  accurately  brought  together,  and  no  time  will  be  lost  in  searching 
for  them. 

Eedo-vaglnal  Fistula. — This  is  perhaps  the  most  frequent  of  all  com- 
plicated fistulas.  It  consists  in  an  abnormal  opening  between  the  rectum 
and  the  vagina  proper,  or  that  part  of  the  female  genital  tract  posterior 
to  the  hymen  or  its  remains.  It  may  be  direct  or  indirect,  depending 
largely  upon  its  catise  and  the  size  of  the  openings.  It  results  from 
a  variet}'  of  cattses,  the  comparative  frequency  of  which  it  is  impos- 
sible to  estimate.  Kelsey  states  that  it  is  nearly  always  due  to  the 
imperfect  repair  of  the  perineum  after  rupture  during  childbirth. 
]\Iunde  (Boston  Med.  Journal,  1885)  has  reported  a  case  resulting  from 
brutal  coitus.  It  is  frequently  the  result  of  an  incomplete  tear  of  the 
peringeum,  such  as  may  be  described  as  a  submucous  rupture  of  the 
recto-vaginal  septum.  Sloughing  of  this  sseptum,  owing  to  prolonged 
pressure  by  the  foetal  head,  is  also  a  cause.  The  communication  does 
not  take  place  until  several  days  after  labor,  just  as  in  the  case  of  vesico- 
vaginal fistula. 

S^-philitic  ulceration,  with  or  without  stricture,  is  a  frequent' cause 
of  this  type  of  fistula.  In  one  year  the  author  observed  6  cases  of  this 
condition  in  -i  of  which  there  was  stricture  of  the  rectum;  all  of  the 
patients  were  syphilitic,  and  the  ulcerations  bore  the  indubitable  evi- 
dence of  the  disease.  It  has  also  been  observed  in  cases  of  simple  cica- 
tricial stricture  of  the  rectum. 

Tubercular  ulceration  of  the  rectum  may  result  in  a  fistula  of  this 
type,  but  certainly  it  is  a  very  rare  cause.  Carcinoma  of  the  rectum 
or  vagina  frequently  results  in  a  communication  between  the  two  cavi- 
ties. Sloughing  of  the  sseptum,  due  to  an  operation  for  hemorrhoids, 
has  been  mentioned  by  Quenu  and  Hartmann  as  a  cause,  and  one  can 
easily  see  how  too  large  a  bite  with  a  hsemorrhoidal  forceps  or  with  the 
ligature  may  result  in  this  condition.  Prolonged  pressure  upon  the 
recto-vaginal  sseptum  from  any  cause  may  result  in  sloughing  and  the 
formation  of  recto-vaginal  fistulas.  The  writer  has  removed  a  glass 
pessary  from  the  rectum  which  had  ulcerated  through  the  sEeptum  and 
left  a  large  opening  between  the  two  cavities  into  which  three  fingers 
could  be  easily  introduced. 

Fistulas  of  this  ty[3e  may  also  result  from  abscess  developing  in  the 
sseptum,  from  tumors  of  the  perina}um,  dermoid  cysts,  or  from  foreign 
bodies  in  the  intestinal  canal,  such  as  pins,  fish-bones,  etc.,  which  pene- 
trate the  ssepttim,  especially  in  cases  of  anterior  rectocele. 

Large  pelvi-rectal  abscesses  developing  in  women  may  burrow  down 
29 


450  THE  AXTS,  RECTUM,  AXD   PELVIC  COLON 

between  the  layers  of  this  saeptum  and  open  both  into  the  rectum  and 
into  the  vagina,  thus  constituting-  a  recto-vaginal  fistula.  The  fistulous 
tract  in  these  cases  may  not  be  direct,  but  open  at  one  level  into  the 
vagina,  and  at  another  into  the  rectum  with  an  irregular  abscess  cavity 
intervening. 

Symptoms. — Except  in  those  cases  resulting  from  abscesses,  ulcera- 
tions, and  neoplasms,  few  subjective  symptoms  will  precede  the  forma- 
tion of  the  fistula.  The  history  of  traumatism  or  accidents  in  child- 
birth, the  prolonged  retention  of  the  head  in  the  hollow  of  the  sacrum, 
rupture  of  the  perinaeum  and  efforts  at  its  repair,  will  all  point  to  the 
cause  of  the  fistula. 

The  diagnosis  is  very  simple.  The  escape  of  gas  and  faces  through 
the  vagina  at  the  time  of  defecation,  or  involuntarily,  leave  no  doubt  in 
the  patient's  mind  as  to  an  abnormal  commimication.  The  presence 
of  fa?cal  material  in  the  vagina,  the  vaginitis  and  leucorrhoea  resulting 
therefrom,  are  the  distressing  features  of  these  cases.  They  not  only 
cause  pain  and  irritation,  but  mortification  and  uneasiness  to  the  indi- 
vidual, resulting  sometimes  in  melancholia  and  even  in  suicide. 

The  opening  can  generally  be  seen  in  the  vagina  witli  the  aid  of  a 
Sims's  speculum  introduced  into  the  anterior  commissure.  It  may 
also  b&  felt  with  the  finger  in  the  rectum,  or  seen  through  the  ordinary 
fenestrated  speculum.  Ordinarily  the  opening  is  large  enough  to  admit 
the  end  of  the  finger,  and  frequently  much  larger.  It  is  generally  in 
the  median  line  and  within  the  first  2  inches  above  the  anus.  The  tract 
is  ordinarily  short  and  direct.  It  may.  however,  be  diagonal  and  some- 
what elongated  when  it  occurs  from  puncture,  abscesses,  or  neoplasms 
in  the  recto-vaginal  sseptum.  In  the  beginning  of  the  condition  there 
is  ordinarily  a  discharge  of  pus,  and  sometimes  blood  with  the  faecal  pas- 
sages or  from  the  vagina.  After  a  period,  however,  the  pus  ceases  to 
discharge,  and  the  condition  occasions  the  patient  no  pain  except  that 
due  to  the  vaginitis.  In  this  state  the  tract  will  be  found  lined  through- 
out with  mucous  membrane,  and  it  will  be  impossible  to  decide  where 
that  of  the  rectum  ends  and  that  of  the  vagina  begins,  the  epithelial  sur- 
faces gradually  blending  at  an  indeterminable  point. 

In  cases  where  the  tract  is  oblique  the  openings  upon  both  surfaces 
are  flap-like,  and  it  may  be  difficult  to  find  them.  If,  however,  the 
patient  frequently  passes  gas  from  the  vagina,  the  diagnosis  may  be 
considered  established  and  the  search  should  not  be  given  tip.  Wliere 
there  is  a  stricture  of  the  rectum  the  fistulous  conununication  will 
almost  always  be  found  below  it. 

Treatment. — The  treatment  of  this  condition  has  not  been  invariably 
successful,  and  it  is  no  unusual  thing  to  see  patients  who  have  under- 
gone three,  four,  and  even  more  operations  for  the  closure  of  these 


COMPLICATED  FISTULA  451 

fistulas,  and  all  in  vain.  A  very  small  proportion  of  them  may  be  closed 
by  cauterization  and  local  treatment  of  the  fistulous  tract,  but  in  the 
large  majority  this  will  fail.  The  instruments  and  tampons  devised  for 
carrying  the  fffical  current  past  the  fistulous  opening  have  not  been  suc- 
cessful. Prolonged  constipation  of  the  bowels  after  cauterization  of  the 
fistulous  tract  is  more  likely  to  be  successful  than  any  of  these  appliances. 

As  a  rule,  however,  some  surgical  procedure  will  be  necessary,  and  of 
these  there  is  a  large  variety.  They  may  be  divided  into  three  types: 
operations  upon  the  fistulous  opening  through  the  rectum,  operations 
upon  the  fistulous  opening  through  the  vagina,  and  complete  excision 
of  the  fistulous  tract  combined  with  peringeorrhaphy. 

Operations  through  the  Rectum. — Inasmuch  as  the  isecal  and  gaseous 
passages  which  are  supposed  to  keep  these  fistulas  open  proceed  from 
the  rectum,  it  would  appear  more  rational  to  close  the  fistulous  open- 
ing upon  this  side  and  thus  obviate  the  escape  of  these  substances  into 
the  tract.  If  this  could  be  successfully  done,  in  all  probability  the  rest 
of  the  fistulous  tract  between  it  and  the  vagina  would  heal  spontaneously. 
The  difficulties  in  this  operation  consist  in  the  impossibility  of  absolute 
asepsis,  the  constant  mobility  of  the  rectal  wall  on  account  of  peristaltic 
contractions,  and,  finally,  the  difficulty  in  reaching  the  opening  through 
the  anus.  Prolonged  preparation  combined  with  intestinal  antiseptics 
and  frequent  douches  will  do  much  to  overcome  the  first.  Opium  in 
large  doses  will  practically  control  the  second,  but  the  difficulties  of 
approach,  when  the  fistulous  opening  is  high  wp  in  the  rectal  cavity, 
are  not  so  easily  overcome.  Terrier  and  Hartmann  (Annates  de  gynec, 
Paris,  1891,  vol.  ii,  p.  192),  Heydenreich  {ihid.,  1894,  t.  ii,  p.  341),  and 
Demarquay  have  attempted  to  accomplish  this  by  splitting  the  anus  and 
rectum  posteriorly  and  removing  the  coccyx,  or  by  doing  a  practical 
Kraske  operation.  The  seriousness  of  such  operations  is  out  of  all  pro- 
portion to  the  gravity  of  the  condition.  If  the  opening  can  be  reached 
and  sutured  by  an  incision  through  the  posterior  commissure  of  the 
anus  no  permanent  ill  effects  will  be  likely  to  follow  this.  Upon  the 
whole,  however,  one  must  admit  that  the  results  of  plastic  operation 
upon  the  rectal  end  of  these  fistulas  do  not  justify  either  of  these 
procedures.  Occasionally,  when  the  opening  is  small  and  low  down, 
one  may  freshen  the  rectal  opening  and  close  it  successfully  by  sutures; 
but  where  the  opening  is  large  and  some  distance  above  the  anus,  opera- 
tions through  the  vagina  or  through  the  perineum  are  more  likely  to  be 
successful. 

Operations  upon  the  Vaginal  TFa//. — The  simplest  of  these  is  that 
advised  by  Lauenstein  (Fig.  162),  which  consists  in  denuding  the  fistu- 
lous tract  down  to  the  rectal  mucous  membrane  from  the  vaginal  surfaces. 
Stitches  are  then  introduced  from  the  vaginal  side  embracing  all  the 


452 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


Fig.  162. — Lalexstein's  Operation  kok 
Eecto-vaginal  Fistula. 


tissue  of  the  recto-vaginal  septum  except  the  mucous  membrane  of  the 
rectum,  and  the  wound  is  thus  closed.  The  sutures  should  be  of  silver 
wire,  and  introduced  in  whatever  direction  will  bring  the  parts  together 

most  accurately  and  with  the  least 
tension.  No  effort  is  made  to  close 
the  opening  in  the  rectal  mucous 
membrane.  It  is  wise,  however,  after 
having  sutured  the  fistula,  to  stretch 
the  sphincter,  introduce  a  rectal  tube, 
and  constipate  the  patient  in  order 
that  no  fluid  ffiecal  matter  shall  in- 
fect the  wound,  and  that  there  shall 
be  a  free  escape  of  the  intestinal 
gases  through  the  anus.  Fergusson 
dissects  up  a  cuff  of  mucous  mem- 
brane upon  the  vaginal  side  about  ^ 
an  inch  outside  of  and  surrounding 
the  fistulous  opening.  This  cuff  is 
dissected  inward  toward  the  fistula, 
but  left  attached  around  the  margin 
of  the  opening;  it  is  then  caught  to- 
gether in  the  center  and  invaginated  through  the  fistulous  tract  into 
the  rectum,  where  it  is  grasped  by  a  haemorrhoidal  or  narrow-bladed 
clamp,  and  held  in  this  position  while  the  freshened  surfaces  around 
the  fistula  in  the  vagina  are  brought  together  with  silver  or  silkworm- 
gut  sutures.  The  inverted  flap  closes  the  opening  into  the  rectum 
for  the  time  being,  and  prevents  the  escape  of  gas  and  fsecal  material 
into  the  fistula  until  the  freshened  surfaces  have  had  an  opportunity  to 
unite.  The  same  precautions  should  be  exercised  here  as  advised  above 
with  regard  to  stretching  the  sphincter,  constipating  the  patient,  and 
introducing  a  tube. 

Various  modifications  of  the  flap  operation  have  been  devised.  They 
all  consist  in  attempts  to  close  the  fistula  by  sliding  or  transplanting 
flaps  from  the  vaginal  wall  over  the  fistulous  opening.  In  some  the 
tract  itself  is  dissected  out  and  sutured,  in  others  no  attention  is  paid 
to  the  tract,  and  it  is  attempted  to  close  the  fistula  by  placing  a  patch 
of  one  or  two  layers  of  vaginal  mucous  membrane  over  the  anterior  aper- 
ture. Among  these  operations  may  be  mentioned  those  of  Montgomery 
(Gynecology,  p.  224),  Saenger  (Transactions  of  the  Amer.  Ass'n  of  Ob- 
stet.  and  Gynecol.,  1890,  p.  359),  Schauta  (Centralblatt  f.  Gyniikol.,  Leip- 
zig, 1886,  S.  485),  Fritsch  (Centralblatt  f.  Gynakol.,  Leipzig,  1888,  S. 
804),  and  Le  Dentu  (Annales  de  gynecoL,  1890,  p.  336).  They  are  all 
ingenious,  but  more  or  less  complicated.    The  simple  methods  of  Lauen- 


COMPLICATED  FISTULA 


453 


stein  and  Fergusson  will  accomplish  all  that  can  be  clone  by  these  com- 
plicated procedures.  Where  these  plastic  operations  have  failed,  or 
where  the  fistula  is  associated  with  ruptured  perinseum,  some  operation 
designed  for  its  closure  and  the  repair  of  the  rupture  at  the  same  time 
should  be  employed. 

Complete  Excision  of  the  Fistulous  Tract  combined  with  PerincBor- 
rhaphy.— The  technique  employed  by  the  author  in  this  operation  is 
as  follows: 

The  sphincter  muscle  should  be  thoroughly  but  gently  stretched; 
the  perineum  is  then  completely  incised  from  the  yagina  into  the  rec- 
tum up  to,  but  not  including  the  fistula;  a  probe  is  then  passed  through 


Fig.  KiS. — Closure  of  Kecto-vaginal  Fistt'la,  biiowim.  Mi cnr 
OF  Eectum  and  Sutured  to  the  Skin. 


,.\r   i;i:"i  i.ii  i 


the  fistula,  and  the  latter,  together  with  all  its  cicatricial  tissue,  is  dis- 
sected out  en  masse.  The  mucous  membrane  of  the  rectum  is  trimmed 
off  from  the  edges  of  the  wound  for  about  ^  an  inch  up  to  the  level" 
of  the  fistulous  opening,  and  above  this  it  is  loosened  from  its  attach- 
ments until  it  can  be  brought  down  to  the  margin  of  the  anus;  the 
perineal  septum  is  then  brought  together  down  to  and  including  the 
sphincter  muscle  with  a  continuous  chromicized  catgut  suture.  Three 
or  four  deep  silver-wire  sutures  are  then  passed  through  the  perineum, 
after  the  manner  of  Emmet.     Before  the  latter  are  fastened,  the  mu- 


454  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

cons  flap  in  the  rectum  is  brought  down  and  sutured  to  the  skin  at 
the  margin  of  the  anus  (Fig.  1G3);  the  wire  sutures  are  then  drawn 
together  and  made  fast  by  twisting  or  by  perforated  shot,  and  finally 
the  edges  of  the  mucous  membrane  in  the  vagina  are  sutured  with  plain 
catgut  and  sealed  over  with  iodoformized  collodion.  The  operation  con- 
sists in  doing  practically  a  Whitehead  operation  upon  the  anterior  wall 
of  the  rectum  combined  with  a  complete  perinajorrhaphy.  The  mucous 
flap  closes  all  conunimication  between  the  rectum  and  the  perineal 
wound,  and  thus  protects  the  latter  from  fscal  and  gaseous  passages.  A 
small  drainage-tube  is  placed  in  the  rectum  to  facilitate  the  escape  of 
gases,  and  the  patient's  bowels  are  constipated  for  six  or  seven  days. 
After  this  period  injections  of  oil  and  glycerin  may  be  given  to  soften 
the  facal  materials,  but  under  no  circumstances  except  real  danger  to 
the  life  of  the  patient  should  a  purgative  be  given  until  the  hard  faecal 
accumulations  have  been  removed  or  softened.  The  wire  sutures  are  re- 
moved on  the  eighth  day.  In  7  cases  done  by  this  method  not  a  single 
failure  has  occurred.  In  one  instance,  in  which  complete  laceration 
of  the  perina?um  and  efforts  at  repair  had  resulted  in  great  destruction  of 
tissue,  it  was  impossible  to  bring  the  parts  accurateh'  together  without 
great  constriction  of  the  anus;  this  difflculty  was  overcome  by  incising 
the  rectum  in  a  V-shape  posteriorly  (Fig.  108),  thus  relaxing  the  sphinc- 
ter muscles  and  allowing  the  parts  to  be  brought  into  more  perfect  ap- 
position. Xo  incontinence  followed  this  operation,  and  from  being  one 
of  the  most  despondent  and  miserable  of  women,  this  patient  was  enabled 
to  enjoy  society  and  travel  without  any  fear  of  involuntary  discharges 
and  the  personal  mortification  consequent  thereto. 

In  a  certain  number  of  cases  the  extensive  destruction  of  tissue 
renders  it  impossible  to  restore  the  rectal  wall  without  causing  a  stric- 
ture. In  a  patient  from  whom  a  glass  pessary  was  removed  through 
the  anus,  inasmuch  as  she  had  passed  the  menopause,  it  was  considered 
wise  to  freshen  the  anterior  lip  of  the  cervix  and  suture  this  to  the 
freshened  surfaces  of  the  lower  margin  of  the  fistula,  thus  turning  the 
mouth  of  the  uterus  into  the  rectum.  By  this  means  the  opening  was 
effectually  closed.  Sunon  has  advised  closing  apertures  of  this  kind 
by  a  flap  taken  from  the  posterior  lip  of  the  cervix.  The  advice  of 
Eose  and  C'zerny  to  precede  this  operation  by  inguinal  colotoni}',  with 
the  hope  that  the  recto-vaginal  fistula  will  close  spontaneously,  is  illu- 
sory and  apparently  unjustifiable. 

EpiseiocJeisis  has  been  advised  by  Kaltenbach  (Centralblatt  f .  Gynak., 
1883,  Xo.  48)  in  these  cases,  but  it  has  never  met  with  great  favor  in 
this  country.  One  of  the  plastic  methods,  or  the  modified  perinaBor- 
rhaphy  described  above,  will  generally  give  the  most  satisfactor}'  results. 


CHAPTER   XIII 

STRICTURE  OF  THE  RECTUM 

Steicttjees  of  the  rectum  are  spoken  of  as  annular,  valvular,  tubular, 
and  linear,  according  to  the  shape  which  they  take.  The  annular  stric- 
ture is  one  which  assumes  the  shape  of  a  ring,  involving  only  a  very 
small  extent  of  the  rectum,  but  completely  surrounding  it.  The  valvu- 
lar stricture  was  formerly  understood  to  mean  that  condition  in  which 
a  fold  of  mucous  or  fibrous  tissue  extended  partially  across  the  lower  end 
of  the  rectum  or  upper  portion  of  the  anus.  This  condition  is  con- 
genital, and  has  been  described  in  the.  chapter  on  Malformations.  The 
term  has  been  applied  of  late  to  cases  in  which  there  was  inflammation, 
thickening  and  tension  at  the  margin  of  the  valves  of  Houston;  these, 
strictly  speaking,  are  obstructions  and  not  strictures.  The  tubular  stric- 
ture, sometimes  called  "  cannular,"  consists  in  a  tube-like  contraction  of 
the  rectum  that  extends  for  1  inch  or  more  in  its  length,  in  which  the 
entire  circumference  and  all  the  tunics  take  part.  The  linear  stricture 
consists  in  a  cicatricial  or  fibrous  deposit  over  a  limited  area  in  the  cir- 
cumference of  the  intestine  by  which  the  caliber  of  the  latter  is  les- 
sened either  through  the  dimensions  of  the  deposit  itself  or  through 
the  contraction  of  the  walls  of  the  gut  over  the  area  which  it  occupies. 

Strictures  are  spoken  of  as  of  large  and  small  caliber  according  to 
the  amount  of  coarctation  which  they  produce.  We  also  read  of  con- 
genital and  acquired  stricture,  simple,  cicatricial,  spasmodic,  soft,  hard, 
malignant,  and  benign  strictures.  The  last  term  is  a  misnomer,  for  as 
Cripps  {op.  cit.,  p.  315)  has  well  said,  every  stricture  if  left  alone  eventu- 
ally results  fatally,  if  not  from  the  disease  itself,  at  least  from  the 
symptoms  which- follow  in  its  wake  and  shorten  life.  According  to  their 
supposed  etiology  strictures  are  divided  into  congenital,  neoplastic,  trau- 
matic, tubercular,  syphilitic,  gonorrlioeal,  dysenteric,  and  inflammatory. 
All  except  the  first  two  are  included  in  the  general  term  inflammatory 
stricture,  and  we  therefore  adopt  the  following  divisions: 

Congenital  Strictures,  Neoplastic  Strictures,  Spasmodic  Strictures, 
Inflammatory  Strictures. 

455 


456  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

The  shape  of  the  stricture  may  modify  to  a  certain  extent  the  surgical 
procedures  applicable  to  its  management,  but  it  has  little  if  anything 
to  do  with  the  pathological  nature  of  the  disease.  Before  discussing 
these  types,  reference  must  be  made  to  strictures  which  do  not  constrict, 
or  at  least  do  so  in  a  very  slight  degree. 

Stricture  of  Large  Caliber. — Every  surgeon  is  familiar  with  the  period 
when  it  was  tlio  custom  to  introduce  an  ordinary  steel  sound  of  very 
moderate  size  into  the  uretlira,  and  if  it  passed  backward  without  abso- 
lute obstruction,  pronounce  the  patient  free  from  stricture.  Later  on, 
cases  arose  with  symptoms  referable  to  the  urethra,  and  yet  in  which 
the  ordinary  methods  of  examination  failed  to  show  any  condition  to 
account  for  them.  The  invention  of  the  bulbous  bougie,  and  after  this 
the  urethrometer,  established  the  fact  that  aside  from  the  normal  coarc- 
tations of  the  urethra  there  frequently  occurred  from  jiathological  con- 
ditions slight  contractions  in  calil)er  that  gave  rise  to  certain  neuralgic 
and  reflex  symptoms  which  before  this  time  were  little  understood  and 
not  at  all  amenable  to  treatment.  The  discovery  of  this  condition  led 
to  new  and  revised  methods  of  treatment,  and  the  consequent  cure  of 
many  cases  which  had  hitherto  baffled  the  efi^orts  of  surgery.  Tlie  same 
conditions  exist  in  the  rectum.  Small  cicatricial  or  connective-tissue 
deposits  in  the  walls  of  such  canals  as  the  urethra  and  rectum  are  con- 
stant sources  of  irritation  because  of  the  friction  produced  by  the  passage 
of  faecal  matter  and  urine  over  them.  It  is  not  necessary  that  the  caliber 
of  the  canal  shall  be  so  contracted  as  to  produce  an  absolute  obstruction 
in  order  to  produce  irritative  symptoms.  As  an  evidence  of  this  the 
following  cases  are  cited: 

Mrs.  L.  was  operated  for  a  small  post-rectal  fibroid  on  October  15,  1894,  and 
the  operation  was  followed  by  some  ulceration  at  the  point  from  which  the  tumor 
was  removed ;  but  this  healed,  and  the  patient  seemed  to  recover  entirely  within 
due  time.  She  sought  advice  five  years  later,  describing  herself  as  suffering  from 
a  frequent  desire  to  defecate,  a  slight  discharge  of  mucus  which  stained  her  linen, 
and  constant  aching  pain  in  the  back  and  pelvis.  A  careful  examination  showed 
the  existence  of  the  cicatrix  at  the  left  posterior  quadrant  of  the  rectum,  but  it 
was  not  painful;  and  as  it  was  possible  to  introduce  a  No.  10  Wales  bougie,  it 
did  not  seem  probable  that  the  cicatrix  was  the  cause  of  her  suffering.  A  slight 
hypertrophic  catarrh  existed,  and  she  was  also  nearing  the  menopause  with  a  sub- 
involuted  uterus.  The  treatment  included  rectal  lavage,  the  regulation  of  the 
diet,  and  occasional  administration  of  such  sedative  and  antineuralgic  remedies  as 
her  family  physician  had  found  to  relieve  her,  in  the  hope  that  by  tiding  her  over 
the  climacteric  she  would  be  relieved  of  her  pains.  Two  years  later  the  woman 
consulted  the  author  again,  this  time  in  desperation ;  formerly  she  had  positiv'ely 
refused  to  consider  any  operation,  but  at  this  time  her  first  remark  upon  entering  my 
ofiice  was,  "I  am  here  to  do  anything  you  say  to  get  relief."  Her  neuralgia  had 
continued  during  the  two  years  since  she  had  been  seen.  An  examination  of  the 
rectum  elicited  the  fact  that  the  fibrous  deposit  had  extended  farther  around  the 


STEICTLTRE   OF   THE  RECTUM  457 

rectum,  involving  about  one-third  of  the  circumference;  the  mucous  membrane 
over  it  was  slightly  redder  than  normal,  but  the  caliber  of  the  gut  was  very  little 
reduced.  On  September  19,  1900,  this  tissue  was  excised  and  the  mucous  mem- 
brane was  sutured  over  the  wound.  From  the  day  of  the  operation  this  patient's 
neuralgia  absolutely  ceased,  the  pains  in  her  hips  and  legs  disappeared,  and  she 
wrote  three  months  later  that  she  was  perfectly  well. 

In  another  case  of  this  nature  in  which  there  was  no  history  of  an  operation, 
but  of  a  ''  dysentery,"  as  she  called  it,  about  fourteen  years  previously,  the  patient 
complained  of  an  inclination  to  go  to  the  closet  frequently,  a  feeling  of  pain  and 
dragging  when  her  bowels  moved,  and  an  aching  in  the  back  and  pelvis  for  some 
time  after  stool.  Examination  of  the  rectum  with  the  finger  showed  no  abnor- 
malities below,  but  about  3|  inches  above  the  anus  a  narrow,  submucous  band 
surrounding  the  lateral  and  anterior  two-thirds  of  the  rectum  could  be  felt.  It 
was  not  a  normal  narrowing,  but  a  distinct  band  surrounding  the  rectum,  and 
by  pressure  upon  it  it  was  possible  to  produce  the  same  pains  of  which  the 
woman  complained  when  she  had  well-formed  faecal  passages.  There  was  no 
cicatrization  or  evidence  of  preceding  ulcerations  in  the  mucous  membrane  of  the 
rectum,  and  so  far  as  could  be  made  out  by  palpation  there  was  no  great  thicken- 
ing of  the  tissues;  full-sized  bougies  passed  without  difficulty,  but  did  not  give 
much  relief.  The  hand  passed  into  the  rectum  felt  this  annular  contraction,  about 
the  caliber  of  a  good-sized  shoestring,  entirely  surrounding  the  intestine.  By 
gradually  insinuating  the  palm  of  the  hand  through  this  portion  and  folding  the 
fingers  so  as  to  increase  the  circumference,  the  band  gave  way  and  the  normal 
caliber  of  the  rectum  was  immediately  restored.  The  patient  was  watched  care- 
fully for  the  next  two  days,  but,  so  far  from  having  any  alarming  symiitoms,  she 
had  immediate  relief  from  the  constant  desire  to  defecate;  and  when  on  the  second 
day  following  the  operation  her  bowels  moved,  she  was  delighted  to  find  that  it 
was  without  straining,  and  accompanied  with  no  pain  whatever. 

Some  readers  will  attribute  the  result  in  both  of  these  cases  to  the 
divulsion  of  the  sphincter,  but  in  neither  was  there  any  unusual  con- 
traction or  spasm  of  this  muscle,  and  more  than  that,  both  cases  had 
been  treated  by  gradual  and  forcible  dilatation  of  the  sphincter  before 
they  were  finally  operated  on.  Three  other  cases  of  this  nature  have 
been  seen  at  the  clinic,  in  all  of  which  the  symptoms  appeared  to  be 
due  to  the  irritation  of  the  fibrous  deposit  and  not  to  any  marked  nar- 
rowing of  the  gut. 

The  cases  presented  are  too  few  to  base  conclusions  upon,  but  they 
are  suggestive  at  least  of  a  possible  obscure  cause  of  many  rectal  symp- 
toms which  the  ordinary  treatment  fails  to  relieve. 

Obstructions  to  fscal  passages  from  pressure  by  pelvic  organs,  tu- 
mors, pessaries,  etc.,  outside  of  the  rectal  wall,  can  not  properly  be  called 
strictures  of  the  rectum,  but  they  produce  similar  symptoms  and  may 
excite  an  inflammation  in  its  walls  which  will  eventually  produce 
them. 


45S  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

CONGENITAL    STRICTURES  ^ 

The  subject  of  congenital  strictures  has  been  already  considered  in 
the  chapter  upon  Malformations.  At  the  risk  of  repetition,  however, 
we  may  say  here  that  this  condition  is  frequently  unobserved  until  later 
on  in  life,  when,  on  account  of  change  in  food  and  habits,  the  patient's 
stools  become  more  solid,  and  difficulty  in  the  passages  begins  to  be  felt. 
Patients  assume  that  this  condition  is  simple  constipation,  and  pay  little 
attention  to  it  until  the  necessary  straining  produces  fissure,  luemor- 
rhoids,  or  other  inflammations  of  the  rectum  or  anus.  This  usually 
occurs  about  the  age  of  pubert}'.  Under  these  circumstances  they  con- 
sult the  doctor,  and  upon  finding  a  strictured  condition  about  the  margin 
of  the  anus,  or  Just  below  the  level  of  the  internal  sphincter,  he  is  very 
liable  to  be  misled  in  regard  to  the  nature  and  etiology  of  the  same.  A 
very  careful  examination  into  the  history  of  such  patients  will  be  neces- 
sary^ to  establish  the  true  state  of  affairs.  It  is  not  to  be  supposed  that 
a  patient  will  develop  a  cicatricial  or  fibrous  stricture  without  the  history 
of  some  inflammatory  or  ulcerative  condition  having  preceded  it.  These 
cases  can  give  no  history  of  any  rectal  condition  beyond  that  of  gradually 
increasing  constipation.  Many  of  them  will  be  able  to  recall  the  fact 
that  constipation  had  existed  from  early  infancy,  that  it  was  better  for 
a  period  during  childhood,  began  again  at  tlie  age  of  twelve  or  fifteen, 
and  after  this  time  it  gradually  grew  worse.  The  use  of  enemata  and 
laxatives  will  have  become  an  established  habit  with  such  individuals 
in  early  life.  Ordinarily  there  will  be  no  evidence  of  loss  of  tissue,  but 
rather  an  abnormal  development.  The  stricture  in  such  cases  is  usually 
about  ^  to  f  of  an  inch  above  the  margin  of  the  anus.  It  may  consist 
in  one  well-defined  band,  or  sometimes  a  circular  fold  with  an  opening 
in  the  center  or  on  the  side.  The  sphincter  muscle  may  or  may  not  be 
hypertrophied,  but  it  is  absolutely  distinct  from  the  fibrous  band  which 
forms  the  stricture. 

"When  these  strictures  are  seen  after  the  age  of  puberty,  they  are 
generally  quite  dense  and  difficult  to  dilate;  in  a  young  woman  twenty- 
three  years  of  age  it  was  impossible  even  by  the  exercise  of  considerable 
strength  to  dilate  the  parts  sufficiently  to  introduce  a  good-sized  Sims's 
speculum,  and  in  order  to  accomplish  this  it  was  necessary  to  cut  the 
stricture.  The  fibrous  tissue  was  removed  by  dissection,  and  was  more 
than  ^  of  an  inch  in  thickness,  dense,  hard,  and  almost  cartilaginous. 
After  having  removed  it,  the  mucous  membrane  of  the  rectum  was  dis- 
sected up  and  sutured  to  the  margin  of  the  skin  just  over  the  external 
sphincter.  The  patient  made  an  excellent  recovery,  and  all  her  symp- 
toms were  relieved.  Ordinarily,  however,  such  stricture  will  not  be 
found  so  dense,  and  gradual  dilatation  with  small  incisions  at  several 


STRICTURE   OF   THE  RECTUM  459 

points  in  the  circumference  will  accomplish  a  cure  in  these  conditions. 
It  is  unnecessary  to  repeat  what  has  been  said  upon  this  subject  in  the 
chapter  on  Malformations^  but  this  will  serve  to  call  the  reader's  atten- 
tion to  the  possible  congenital  nature  of  the  strictures  found  low  down 
in  the  rectum. 

NEOPLASTIC    STRICTURE 

The  rectum  may  be  obstructed  by  a  new  growth  inside  of  it  or  within 
its  walls.  Unless  such  a  growth  forms  a  true  constriction  of  the  rectal 
caliber  it  can  not  properly  be  called  a  stricture;  a  polypus  may  completely 
fill  up  the  rectal  cavity,  and  yet  it  does  not  comprise  in  any  way  a  stric- 
ture; the  same  may  be  said  of  fibroids,  of  papillomata,  and  of  condylomata, 
they  are  obstructions  but  not  strictures.  Such  growths  will  therefore 
be  considered  in  the  chapters  on  jSTeoplasms  of  the  Eectum.  Malignant 
growths,  such  as  sarcomata  and  carcinomata,  not  only  obstruct  the  rectal 
caliber  by  protrusion  into  it,  but  they  also  narrow  it  by  a  fibrous  con- 
traction of  the  walls  of  the  gut.  Especially  is  this  true  of  carcinomata; 
they  form  a  t3'pe  of  stricture  which  is  both  obstructive  and  contracting. 
The  fibrous  portion  of  the  stricture  in  these  cases  may  have  none  of  the 
elements  of  the  neoplasm  in  it,  and  is  probably  of  an  inflammatory 
nature;  but  it  is  of  small  importance  compared  with  the  neoplasm  that 
causes  it.  When  malignant  growths  have  once  been  established,  total 
extirpation  ofi^ers  the  only  ground  of  hoj)e  for  the  patient,  and  the  stric- 
ture is  always  included  in  this.  These  strictures  will  therefore  be  con- 
sidered in  the  chapter  on  Malignant  Neoplasms  of  the  Rectum.  The 
present  chapter  is  limited  to  the  consideration  of  that  general  type  of 
stricture  produced  by  some  form  of  inflammation.  The  cause  and  extent 
of  the  inflammation,  the  amount  of  tissue  destruction,  and  the  method 
of  healing  will  determine  the  type  of  stricture. 

Before  beginning  to  discuss  the  special  varieties  of  inflammatory 
stricture,  it  will  be  well  to  take  a  hasty  review  of  the  anatomical  con- 
struction of  the  intestinal  walls.  It  will  be  remembered  that  the  rectal 
wall  is  composed  of  four  separate  layers:  the  mucous,  the  submucous, 
the  circular,  and  longitudinal  coats;  and  in  addition  to  these,  in  its 
upper  portion  and  throughout  the  pelvic  colon,  it  is  surrounded  by  the 
peritouEBum.  There  jut  out  into  the  cavity  certain  folds  of  mucous  mem- 
brane between  the  layers  of  which  are  included  connective-tissue  fibers 
with  glandular  and  cellular  substances  between  them.  These  protru- 
sions, called  Houston's  folds  or  valves,  are  fairly  constant  in  certain 
locations  which  are  indicated  by  sulci  upon  the  external  surface  of  the 
gut,  and  give  it  a  convoluted  form.  The  circular  muscular  fibers  are 
divided  by  bands  of  fibrous  tissue  which  extend  circularly  around  the 
canal,  and  outward  anteriorly,  connecting  with  the  fibrous  meshes  of 


460  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

pelvic  tissue,  the  ligament  of  the  bladder,  the  broad  ligaments  of  the 
uterus,  the  prostate,  and  the  fibrous  sheaths  of  the  levator  muscle.  These 
facts  are  important  in  that  they  show  how  the  rectum  may  be  contracted 
not  only  from  inflammatory  processes  in  the  walls  themselves,  but  also 
by  traction  upon  these  circular  fibers  through  the  distention  and  inflam- 
mation of  the  perirectal  tissues.  Moreover,  any  inflammatory  processes 
developing  in  these  tissues  may  travel  along  the  tract  of  these  fibers, 
invade  the  rectal  wall,  and  result  in  a  true  submucous  stricture,  for 
which  no  ulceration  of  the  rectum  or  solution  of  continuity  in  the  mu- 
cous membrane  need  be  evoked  as  the  cause.  The  fact  that  these  cir- 
cular bands  of  fibrous  tissue  enter  into  the  conformation  of  the  valves  of 
Houston  renders  it  easy  of  comprehension  that  contraction  of  these 
valves  may  result  from  perirectal  inflammations  without  any  involve- 
ment of  the  mucous  membrane  or  the  surfaces  of  the  valves  themselves. 
The  majority  of  cases  in  wliich  the  contraction  of  these  valves  has  any 
influence  in  the  production  of  constipation  will  be  found  in  cases  that 
have  had  pelvic,  peri-uterine,  or  periprostatic  inflammations. 


SPASMODIC    STRICTURE 

Under  the  term  spasmodic  stricture  two  conditions  have  been  de- 
scribed which  are  entirely  dissimilar.  In  one  there  is  a  stricture  in 
which  there  are  no  organic  changes  in  the  walls  of  the  gut;  it  consists 
in  a  spasmodic  contraction  of  the  muscles  without  any  actual  shortening. 
In  the  other,  a  condition  is  described  in  which  organic  change  and  per- 
manent constriction  of  the  tube  is  produced  through  persistent  spas- 
modic contraction,  resulting  in  shortening  and  fibrous  transformation 
of  the  muscular  fibers  involved.  While  spasm  of  the  oesophagus  and 
urethra  are  commonly  admitted  by  every  surgeon,  the  existence  of  a 
purely  spasmodic  stricture  of  the  rectum  has  been  denied  almost  uni- 
\^versally.  Van  Buren  (Diseases  of  the  Rectum,  p.  318)  said:  "'No  mod- 
ern authorities  admit  the  existence  of  pure  spasmodic  stricture  of  the 
rectum,  except  in  its  lowermost  portion  where  it  is  surrounded  by  the 
external  sphincter."  He  stated  that  the  majority  of  the  cases  in  which 
such  a  stricture  had  been  diagnosed  were  the  victims  of  hypochondria 
due  to  chronic  constipation  and  dyspepsia;  the  difficulty  in  the  move- 
ment of  the  bowels  suggested  to  them  probability  of  obstruction  or  stric- 
ture, and  the  fact  that  the  passage  of  a  rectal  bougie  stimulated  the 
organ  to  peristaltic  action  and  thus  facilitated  the  fgecal  passages,  tended 
to  confirm  the  erroneous  impression.  Moreover,  the  fact  that  a  rectal 
bougie  is  very  liable  to  be  arrested  by  a  fold  of  mucous  membrane  or  by 
the  promontory  of  the  sacriim,  is  also  likely  to  convince  the  inex- 
perienced surgeon  himself  of  the  existence  of  such  a  stricture.    In  sup- 


STRICTURE  OF   THE  RECTUM  461 

port  of  these  views  Van  Buren  quoted  2  cases,  1  in  the  practice  of  Syme, 
and  1  in  his  own,  in  which  patients  suffered  from  symptoms  of  stricture 
of  the  rectum,  were  treated  for  the  same,  and  yet  upon  post-mortem  no 
stricture  whatever  was  found.  The  cases  cited  are,  unfortunately  for 
his  argument,  just  the  class  for  which  those  who  believe  in  spasmodic 
stricture  of  the  rectum  contend.  The  facts  that  no  organic  stricture 
existed,  that  the  patients'  symptoms  showed  positively  some  obstruction 
to  the  passage  of  fgecal  matter,  and  also  that  the  rectal  bougie  after 
having  passed  through  the  apparent  obstruction  was  still  grasped  and 
held  tightly,  show  very  clearly  that  there  existed  during  life  a  muscular 
spasm  resulting  in  a  greater  or  less  constriction  of  the  rectal  caliber. 
There  is  no  answer  to  the  argument  that,  reasoning  from  analogy,  one 
may  expect  to  find  spasm  of  the  circular  fibers  of  the  rectum  even  more 
marked  than  in  the  oesophagus,  the  larynx,  and  the  urethra.  Contrac- 
tion of  the  circular  fibers  of  the  intestinal  canal  may  be  excited  by  the 
electric  current,  and  it  is  not  unreasonable  to  suppose  that  certain  irri- 
tating substances  may  do  the  same,  and  thus  bring  about  a  spasmodic 
constriction  of  the  rectum.  That  such  a  condition  is  very  frequent  is 
not  asserted,  but  that  it  does  occur,  and  especially  at  the  juncture  of  the 
rectum  with  the  pelvic  colon,  is  absolutely  certain.  The  author  has  time 
and  again  attempted  to  introduce  a  cylindrical  tube  through  this  portion 
of  the  canal,  and  notwithstanding  that  the  direction  of  the  cavity  was 
clearly  in  view,  has  been  unable  to  pass  the  instrument  upward  until 
after  the  spasm  had  relaxed.  Upon  Avithdrawing  the  tube  in  these  con- 
ditions the  parts  may  be  seen  to  contract  like  a  rubber  band,  almost 
entirely  occluding  the  orifice.  Whether  there  exists  in  these  conditions 
some  sensitive  area  of  mucous  membrane  or  some  irritable  nerve-end,  it: 
it  not  possible  to  say,  but  frequently  in  the  same  individual  it  is  impos- 
sible to  introduce  the  tube  on  one  day  on  account  of  such  spasm,  whereas 
on  the  next  it  is  passed  in  without  any  difiiculty;  certainly  there  can  be 
no  pathological  or  organic  change  varying  from  day  to  day  which  would 
cause  such  an  obstruction.  While  prolapse  of  the  sigmoid  into  the  rec- 
tum would  prevent  the  introduction  of  the  tube,  such  a  condition  is  not 
difficult  to  recognize  through  the  instrument,  and  therefore  would  have 
no  weight  in  this  argument.  The  other  condition  which  might  possibly 
account  for  the  changes  from  day  to  day  is  the  angle  of  flexure  of  the  sig- 
moid upon  the  rectum,  which  may  vary.  With  the  pneumatic  sigmoid- 
oscope, when  no  adhesions  exist,  the  sigmoid  may  be  lifted  up  by  infla- 
tion entirely  out  of  the  pelvic  cavity,  and  yet  the  narrowing  at  the  junc- 
ture between  it  and  the  rectum  will  remain  and  appear  larger  at  one  time 
than  at  another.  Sometimes  it  will  admit  a  No.  3  tube,  while  at  others 
it  is  difficult  to  introduce  a  No.  1.  No  one  denies  the  fact  that  spasm  of 
the  sphincters  may  be  so  marked  as  to  interfere  with  stool  or  the  pas- 


462  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

sage  of  instruments,  and  thus  constitutes  a  type  of  stricture  which  may 
be  excited  by  small  ulcerations,  fissures,  or  foreign  bodies.  The  proof 
of  this  lies  in  the  fact  that  the  stricture  disappears  as  soon  as  these  con- 
ditions are  relieved.  Whether  they  are  called  strictures,  constrictions, 
or  muscular  spasm  is  a  matter  of  indifference,  but  the  fact  remains  that 
spasmodic  contraction  of  the  circular  fibers  does  occur,  and  produces 
symptoms  that  resemble  those  of  organic  coarctation. 

Concerning  the  other  type,  that  in  which  organic  changes  follow  a 
persistent  spasm  of  the  muscle,  there  seems  to  be  considerable  differ- 
ence of  opinion.  No  one  claims  that  spasmodic  contraction  of  the 
rectum  can  be  permanent;  Cripps  (op.  cit.,  p.  323),  however,  claims 
that  it  may  continue  long  enough  to  produce  permanent  shortening  of 
the  muscles,  and  cites  as  comparable  to  this  the  contraction  which  occurs 
in  the  hamstring  muscles  in  cases  of  chronic  inflammation  of  the  knee- 
joint,  and  goes  on  to  argue  that  while  such  a  contraction  is  at  first  an 
intermittent  one  resulting  from  irritation  in  the  joint,  after  a  while 
atrophy  of  the  muscular  fibers  takes  place,  and  permanent  shortening 
results.  In  this  stage,  he  says:  "  The  contraction  ceases  to  be  one  of 
muscular  action,  but  the  shortening  remains  permanent  even  after  the 
source  of  the  irritation  has  been  removed."  From  this  analogy  he 
argues  that  any  irritation  in  the  rectum  may  produce  a  similar  con- 
traction of  its  muscular  walls,  and  if  such  irritation  continues  it  may 
result  in  a  permanent  shortening  of  the  fibrous  elements  of  the  muscle, 
thus  producing  fibrous  stricture.  In  support  of  this  view  he  relates 
the  case  of  a  woman  in  whom  he  found  an  ulcer  in  the  posterior  part 
of  the  bowel  with  an  annular  stricture  situated  about  2  inches  from  the 
anus,  well  above  the  sphincters;  upon  examining  the  patient  a  few  days 
later  under  ether  the  ulceration  was  unchanged,  but  the  stricture  had 
practically  disappeared.  He  afterward  learned  that  by  introducing  the 
finger  somewhat  roughly  the  stricture  was  immediately  reproduced,  but 
by  keeping  it  gently  in  contact  with  the  part,  a  gradual  relaxation  took 
place,  so  that  the  finger  would  lie  comparatively  easy  in  the  narrowed 
part;  upon  any  rough  movement  it  could  be  felt  to  be  palpably  and 
immediately  grasped  and  again  relaxed  in  a  few  seconds.  As  the  ulcer 
healed  the  stricture  gradually  disappeared,  and  the  woman  left  the  hos- 
pital apparently  well.  Two  years  later  Dr.  Cripps  was  called  to  see 
this  same  patient.  On  examining  the  rectum  he  found  at  the  site  of 
the  previously  soft  and  yielding  stricture  a  firm,  hard,  unyielding  fibrous 
contraction  narrowing  the  bowel  almost  to  occlusion.  In  support  of  this 
view  Ball  {op.  cit.,  p.  139)  reports  a  similar  case.  They  both  hold  that 
the  irritation  that  occasioned  the  muscular  contraction  had  resulted  in 
a  permanent  shortening  and  alteration  of  the  muscular  fibers,  which 
finally  produced  a  fibrous  stricture  of  the  rectum.     According  to  their 


STRICTURE   OF   THE   RECTUM  463 

views  both  the  circnhir  fibers  and  those  of  the  levator  ani  were  involved. 
The  author  has  seen  this  spasmodic  contraction  of  the  rectum  a  number 
of  times  in  patients  in  whom  there  was  ulceration  of  the  mucous  mem- 
brane. It  is  always  just  above  the  point  of  ulceration,  and  it  is  reason- 
able to  suppose  that  the  repeated  contraction  of  these  muscles  due  to 
irritation  of  the  ffecal  passages  may  result  in  their  shortening,  but  it 
seems  more  rational  to  account  for  the  stricture  by  the  plastic  deposit 
which  occurs  beneath  the  ulceration  and  its  knoAvn  tendency  to  extend 
and  develop  into  fibrous  tissue.  It  apjiears,  therefore,  that  this  type  of 
stricture  is  not  spasmodic,  but  the  result  of  inflammation,  and  should 
be  included  in  the  latter  class. 

INFLAMMATORY    STRICTURES 

These  include  all  those  strictures  due  to  simple,  tubercular,  and  syphi- 
litic inflammations.  The  simple  type  comprises  diffuse  inflanimatory, 
cicatricial,  and  perirectal  strictures. 

The  Location. — The  site  of  inflammatory  strictures  varies  greatly; 
they  may  occur  at  any  point  from  the  margin  of  the  anus  to  the  upper 
limits  of  the  pelvic  colon,  though  the  large  majority  begin  within  the 
first  6  centimeters  of  the  anus.  Excluding  258  cases  collected  by  Perret 
(These,  Paris,  1856,  No.  34),  and  21  by  Quenu  and  Hartmann  {op.  cit., 
vol.  i,  p.  253),  110  additional  cases  have  been  collected;  of  these  the 
sites  were  as  follows: 

Below  6  centimeters  (2-J-  inches) 65 

At  6  centimeters 5 

From  6  to  9  centimeters  (2^  to  3J  inches) 18 

Above  9  centimeters  (3-^  inches) 12 

In  the  pelvic  colon 10 

Quenu  and  Hartmann  in  21  cases  found  only  one  stricture  beginning 
as  high  as  6  centimeters  (2|  inches)  above  the  anus.  In  the  author's 
collection  there  occur  no  less  than  eight  syphilitic  and  four  tubercular 
strictures  above  9  centimeters  (3-|  inches).  There  is  no  question,  how- 
ever, that  the  majority  of  strictures  of  these  parts  are  within  the  first 
8  centimeters  above  the  anus. 

Diffuse  Inflammatory  Stricture. — These  consist  in  an  inflammatory 
or  fibrous  deposit  beneath  the  mucous  membrane.  Lesions  of  this  mem- 
brane may  occur  from  various  causes,  and  heal,  leaving  a  perfectly  nor- 
mal surface  with  plastic  deposit  in  the  submucosa  which  continues  to 
increase,  undergoing  transformation  into  fibrous  tissue  until  it  partially 
or  completely  surrounds  the  rectum,  thus  forming  a  stricture  (Fig.  164). 

In  all  inflammatory  strictures,  whether  simple,  tubercular,  or  syphi- 
litic, the  process  must  involve  the  tissues  below  the  mucosa.     Ulceration 


464 


THE  ANUS,  RECTUM,  AND  PELVIC  COLOX 


or  injury  of  the  mucous  membrane  alone  will  not  produce  a  stricture, 
and  for  this  reason  it  is  rarely  ever  caused  by  simple  catarrhal  diseases. 
If  the  inflammation  once  involves  the  submucosa  it  is  likely  to  extend 
beneath  the  mucous  membrane  in  all  directions,  owing  to  the  distribu- 
tion of  blood-vessels  and  lymphatics  in  this  tissue.  This  causes  the 
diffuse  inflammation  which  is  followed  by  stricture  or  the  reditis 
stenosante  of  French  authors. 

Cicatricial  Stricture. — If  those  which  follow  surgical  operations 
are  excluded,  true  cicatricial  strictures  will  be  foimd  to  be  far  less  fre- 
quent than  is  generally 
supposed.  "Wherever 
the  normal  surface 
membrane  is  restored 
without  intervening 
fibrous  tissue,  no  cica- 
trix can  be  said  to  ex- 
ist. Cicatricial  stric- 
ture, therefore,  must 
be  confined  to  those 
cases  in  which  there 
has  been  destruction 
of  tissues  and  replace- 
ment by  pure  fibrous 
or  cicatricial  material. 
Phlegmonous  and  gan- 
grenous ulcerations, 
such  as  result  from  dif- 
fuse gangrenous  peri- 
proctitis, may  result  in 
cicatricial  stricture  of 
the  rectum.  Opera- 
tions in  which  consid- 
erable areas  of  rectal 
tissue  have  been  re- 
moved, and  healing 
by  granulation  takes 
place,  will  also  occa- 
sion them.  All  sorts  of  traumatisms  which  cause  sloughing  of  the  rec- 
tal wall,  as,  for  example,  prolonged  pressure  of  the  head  during  child- 
birth or  the  retention  of  large  foreign  bodies  in  the  rectum,  may  result  in 
this  tA-pe  of  stricture.  Molliere  has  pointed  out  that  gangrene  of  the  rec- 
tum or  anus  following  certain  forms  of  fever  has  resulted  in  the  destruc- 
tion of  large  areas  of  the  rectum  and  produced  cicatricial  stricture. 


FlO.    164. LOXGITITJINAL    SECTION    OF    STRICTURE    Oi    Tlli: 

Eectum. 


STRICTURE  OF  THE  RECTUM  465 

Kelsey^  Tanchou,  Curling,  Esmarcli,  and  others  have  reported  cases 
of  cicatricial  stricture  that  resulted  from  the  introduction  of  foreign 
bodies  into  the  rectum;  Krouse  (Med.  Record,  1893,  vol.  ii,  p.  506)  re- 
ported a  case  of  cicatricial  stricture  that  resulted  from  a  burn;  Jeannel 
has  related  a  case  in  which  cicatricial  stricture  resulted  from  the  injec- 
tion of  pure  tincture  of  iodine  into  the  rectum;  Quenu  and  Hartmann 
state  that  other  cases  are  due  to  accidental  injections  of  caustic  sub- 
stances, such  as  nitric  or  sulphuric  acid,  into  the  rectum  {op.  cit.,  p.  252). 
The  author  saw  a  stricture  of  this  type  follow  the  accidental  introduc- 
tion of  a  strong  solution  of  chloride  of  zinc  into  the  rectum. 

Cicatricial  stricture  is  one  of  the  complications  or  unfortunate  se- 
quences of  operations  for  excision  or  resection  of  the  rectum  either  by 
the  sacral  or  perineal  methods;  especially  is  this  likely  to  occur  if  end- 
to-end  union  is  attempted  in  that  region  of  the  gut  surrounded  by  the 
levator  ani  muscle.  Operations  for  fistulas  and  for  haemorrhoids  have 
also  resulted  in  this  condition.  Recently,  owing  to  the  attempts  of  in- 
competent surgeons  to  perform  the  Whiitehead  operation,  more  cicatri- 
cial strictures  are  seen  than  formerly.  In  the  Medical  and  Surgical  His- 
tory of  the  War  of  the  Rebellion  there  are  reported  4  cases  of  stricture  of 
the  rectum  due  to  gunshot  injuries;  all  of  these,  however,  suffered  from 
perirectal  inflammation  and  fistula,  together  with  considerable  sloughing 
and  destruction  of  tissue  in  the  rectal  walls  themselves;  in  2  the  wound 
of  the  rectum  was  complicated  by  that  of  the  bladder,  and  in  2  others  of  a 
similar  nature  the  patients  died  from  urinary  extravasation  before  the 
wound  in  the  rectum  healed.  Wherever  an  extensive  destruction  of 
tissue  results  in  a  granulating  ulcer,  an  examination  of  this  condition 
during  the  ulcerative  period  will  always  elicit  a  loss  of  elasticity  in  the 
rectal  wall  due  to  inflammatory  infiltration,  and,  as  Esmarch  held,  this 
infiltration  has  more  to  do  with  the  stricture  than  the  actual  contraction 
of  the  cicatrix.  Quenu  and  Hartmann  state  {op.  cit.,  p.  24)  that  the 
cicatrix  is  not  so  much  the  cause  of  the  stricture  as  is  the  hyperplasia 
in  the  submucous  tissues.  It  may  thus  be  stated  that  the  majority  of 
so-called  cicatricial  strictures  are  really  of  the  diffuse  inflammatory  type. 
The  cicatricial  strictures  which  occur  around  the  margin  of  the  anus 
following  extensive  ulcerations  and  operations  in  this  region  compose 
a  large  percentage  of  those  which  one  meets  with  at  the  present  day; 
there  is  no  restoration  of  the  cutaneous  or  muco-cutaneous  membranes, 
but  a  true,  shining,  cicatricial  mass  takes  their  place. 

Peeirectal  Stkictijees. — By  these  we  mean  those  strictures  which 
develop  from  conditions  outside  of  the  rectum.  Displacements,  enlarge- 
ments, and  tumors  of  the  l^terus,  ovaries,  bladder,  prostate,  or  other 
pelvic  organs  may  cause  obstruction  in  the  rectum  or  sigmoid  by  pres- 
sure, but  these  are  not  strictures.  The  writer  has  seen  one  case  of  abso- 
30 


466  THE  ANUS,  EECTUM,  AND  PELVIC  COLON 

lute  occlusion  of  the  rectal  canal  due  to  extra-uterine  pregnancy;  the 
foetus  broke  through  the  intestinal  wall  and  was  delivered  per  anuni,  hut 
after  this  the  caliber  of  the  gut  was  at  once  restored. 

Local  or  general  peritonitis  not  infrequently  produces  rectal  stric- 
ture. The  adhesive  bands  formed  by  these  intlammations  either  pass 
across  the  gut  and  bind  it  down  to  the  bony  structures  like  a  ligature, 
or  they  may  narrow  its  caliber  by  holding  it  in  an  acutely  flexed  posi- 
tion; this  is  illustrated  by  a  case  in  which  it  was  impossible  to  pass  even 
a  No.  6  Wales  bougie  through  the  first  loop  of  the  sigmoid  flexure  on 
account  of  the  acute  bend  of  the  intestine  at  the  recto-sigmoidal  Juncture 
caused  by  an  adhesive  band  holding  it  down  in  Douglas's  cul-de-sac. 
After  the  adhesion  was  broken  up  and  the  sigmoid  flexure  lifted  out  of 
the  pelvis,  it  was  possible  to  pass  without  any  difficulty  a  jSTo.  13  bougie 
its  full  length.  Hartmann  (Annates  d'gyn.,  Paris,  1894)  has  related  2 
cases  of  this  kind.  Broca  (Bull.  soc.  anat.,  Paris,  1852,  p.  49)  has  de- 
scribed a  case  in  which  two  such  adhesive  bands  embraced  the  rectum, 
almost  encircling  it,  and  caused  constriction.  Inflammatory  adhesion 
of  the  uterus  to  the  rectum  or  to  the  sacrum  at  one  side  or  the  other 
may,  b}^  dragging  the  broad  ligament  of  the  opposite  side  across  the  gut, 
cause  stricture  (Stone  Scott,  Med.  Eecord,  1893,  vol.  ii,  p.  264).  The 
stenosis  in  Scott's  case  was  relieved  by  breaking  up  tlie  adliesions  be- 
tween the  uterus  and  the  sacrum^  and  thus  lifting  the  broad  ligament 
from  the  rectum. 

Another  cause  of  stricture  from  extra-intestinal  conditions  is  adhe- 
sion of  the  appendices  epiploicse  to  the  abdominal  walls,  or,  as  has  been 
seen  recently,  to  one  another.  The  pedicles  pass  across  the  gut  and 
contract  it  to  such  an  extent  that  it  forms  a  perirectal  stricture. 

Many  authors  have  recorded  cases  of  peri-uterine  inflammation  that 
involved  the  rectal  wall  and  caused  inflammation  of  the  same  with  sub- 
sequent stricture  (Balzer,  Bull,  de  la  soc.  anat.,  Paris,  1877,  p.  402; 
Biggs,  Med.  Record,  1893,  vol.  i,  p.  153;  Quenu  and  Hartmann,  vol.  i, 
p.  247).  Cases  have  been  treated  in  which  after  the  uterus  was  dissected 
loose,  the  rectal  wall  remained  thickened,  indurated,  and  contracted  in 
its  caliber.  The  passage  of  rectal  bougies  in  such  conditions  occasioned 
much  pain,  which  was  attributed  to  the  pressure  upon  the  uterus  or  the 
ovary;  while  some  of  the  pain  was  due  to  this,  most  of  it  was  occasioned 
by  the  inflammation  in  the  t.unics  of  the  gut  itself.  The  longer  this 
inflammation  continues  the  greater  will  be  the  development  of  fibrous 
tissue  in  the  walls.  The  circular  muscular  fibers,  owing  to  the  fact  that 
they  are  held  by  adhesions  and  inflammatory  plastic  material  and  can 
not  contract,  will  become  atrophied  and  transformed  into  fibrous  tissue. 

Prostatic  disease  may  also  cause  perirectal  stricture.  The  writer 
once  saw  a  case  of  this  kind.     The  patient  was  sixty-one  years  of  age 


STRICTURE  OP  THE  RECTUM 


467 


and  had  never  suffered  from  venereal  disease^  but  gave  a  history  of 
prostatic  abscess  which  discharged  through  the  urethra.  From  that 
time  forward  he  began 
to  notice  difficulty  in 
stools  and  a  heaviness 
and  weight  in  the  sa- 
crum; he  had  never 
had  any  loss  of  blood 
or  pus  from  the  rec- 
tum, and  no  hiemor- 
rhoids  had  ever  pro- 
lapsed. The  mucous 
membrane  of  the  rec- 
tum, barring  some 
traumatism  made  by 
the  forceps  in  efforts 
to  relieve  an  impac- 
tion, was  absolutely 
healthy,  but  the  organ 
was  bound  closely  to 
the  prostate,  which  was 
large  and  indurated; 
a  circular  fibrous  band 
constricted  the  rectum 
at  the  upper  limits  of 
the  prostate  and 
seemed  continuous 
with  the  capsule  of 
the  gland.  It  had  evi- 
dently been  produced 
by  inflammation  of 
this  organ.  Kirmis- 
son  and  Desnos  (An- 
nales  des  maladies  des 
organ  es  genito-uri- 
naires,  Paris,  t.  vii, 
p.  72)  have  called  at- 
tention to  stricture  of 
the  rectum  resulting 
from  chronic  inflam- 
mation of  the  prostate. 

A  specimen  (Fig.  165)  taken  from  the  body  of  an  old  man  at  the  New 
York  Almshouse  exhibited  a  remarkable  condition  of  affairs.  The  rectum 


Fig.  165. — Stricture  or  Eectum  due  to  Prostatic  Inflam- 
mation. 
A,  perforation   of  rectum :  5,   cavity  iu   which   lemon-seeds 

were    found;     C,    inflammatory    hyperplasia;    D,   perito- 

n£eum. 


468  THE  ANUS,   RECTUM,   AND   PELVIC  COLON 

cousisted  in  a  very  narrow,  tortuous  tract  surrounded  b}-  dense  fibrous 
tissue.  About  3  inches  above  tlie  anus  was  a  perforation  of  its  walls  lead- 
ing to  an  abscess  cavity  in  which  were  several  lemon-seeds.  This  cavity 
appeared  to  be  in  the  lobe  of  the  prostate.  Jeffries,  who  examined  the 
specimen  microscopically,  stated  that  the  tissue  all  around  the  supposed 
rectal  canal  was  of  a  prostatic  nature,  and  that  careful  study  failed 
to  reveal  any  normal  rectal  tissue  whatever.  The  fact  that  the  lemon- 
seeds  were  swallowed  shortly  before  death  and  found  in  this  narrow  tract 
proved  its  connection  M-ith  the  alimentary  canal.  The  patient  was 
brought  into  the  liospital  moribund,  and  consequently  no  history  was 
obtainable.  It  is  without  doubt  a  remarkable  stricture  of  the  rectum 
due  to  prostatic  inflammation  and  h3'pertrophy.  "While  stricture  from 
this  cause  is  rare,  there  are  numerous  cases  in  which  it  has  resulted  from 
pelvi-rectal  abscesses  originating  in  the  prostate  or  in  the  broad  liga- 
ments. 

Blind  external  fistulas  may  be  the  cause  of  perirectal  stricture.  They 
do  not  involve  the  mucous  membrane,  but  cause  inflammation  and  fibrous 
deposit  around  the  gut,  thus  occasioning  true  stricture.  Henry  Smith 
(Surgery  of  the  Recttim,  1876)  states  that  in  such  cases  the  stricture  is 
always  the  cause  of  the  fistula,  but  he  is  certainly  mistaken  in  this. 
Cripps  {op.  cit.,  p.  230)  cites  a  very  interesting  case  in  which  he  was 
able  to  follow  the  patient  from  the  time  the  abscess  appeared  until  the 
stricture  formed.  He  examined  her  tlioroughly  in  the  beginning,  and 
found  no  contraction  of  the  rectal  canal.  She  was  kept  in  the  hospital 
for  twelve  weeks,  no  internal  opening  of  the  fistula  having  ever  devel- 
oped. Eighteen  months  later  she  was  readmitted  to  the  hospital  and 
was  found  to  be  stitfering  from  a  well-marked  stricture.  He  says:  "  It 
is  a  matter  of  some  surprise  that  the  irritation  of  the  fistula  should  so 
seldom  be  followed  by  stricture,  and  I  think  it  will  probably  be  found 
only  when  the  fistitla  extends  some  distance  between  the  coats  of  the 
bowel,  with  a  tendenc}'  to  abscess  formation,  that  the  irritation  is  sufli- 
cient  to  cause  stricture."  The  writer  has  seen  a  patient  in  whom  a 
small  but  deep  perirectal  abscess  was  opened  early  tlirougli  the  peri- 
neum, and  was  followed  by  stricture  of  the  rectum;  there  was  never  any 
lesion  inside  the  rectum,  and  this  abscess  was  the  only  discoverable  cause. 
One  could  argue  that  the  stricture  had  been  occasioned  by  a.  previous 
ulceration  of  this  organ,  but  there  is  not  the  slightest  evidence  of  this. 
With  these  facts  in  view,  it  must  be  concluded  that  true  fibrous  stricture 
of  the  rectum  may  be  occasioned  by  inflammatory  processes  and  irrita- 
tions entirely  outside  of  the  organ,  without  any  infection  from  within  or 
any  solution  of  continuity  in  the  mucous  membrane  of  the  gut. 

In  an  article  entitled  Phantom  Stricture  (Am.  Jour.  Med.  Sci.,  Octo- 
ber, 1879,  p.  334  et  seq.).  Van  Buren  described  -4  or  5  cases  of  this  type  in 


STRICTURE   OF   THE  RECTUM  469 

wliicli  lie  states  that  the  strictures  are  due  to  inflammatory  deposits  in 
the  pelvis  and  about  the  rectum,  or  to  constricting  bands  resulting  from 
pelvic  inflammations  without  involving  the  rectal  wall  itself  in  any 
pathological  changes.  Illustrative  of  how  pelvic  growths  and  malposi- 
tion of  the  uterus  may  simulate  stricture  of  the  rectum,  he  cites  the 
case  of  a  young  woman  of  twenty-flve  who  could  not  relieve  her  bowels 
while  in  the  usual  position,  aad  was  compelled  to  resort  to  the  use  of  a 
bedpan.  As  she  lay  in  the  Sims's  position  nothing  abnormal  could  be 
felt  or  seen  in  the  rectum,  but  when  she  stooped  in  the  squatting  posi- 
tion Van  Buren  was  able  to  recognize  a  globular  tumor  forced  firmly 
backward  into  the  hollow  of  the  sacrum  so  as  to  completely  occlude  the 
rectal  caliber.  This  tumor  proved  to  be  a  fibroma  about  the  size  of  a 
billiard-ball,  which  had  developed  in  the  posterior  wall  of  the  uterus. 
These  conditions,  while  not  constituting  stricture  in  themselves,  may 
produce  it  by  exciting  inflammation  in  the  rectal  Avails  through  pressure 
and  obstruction. 

TuBEECULAK  STEiCTUEE.-^Tlie  existence  of  tubercular  stricture  in 
the  rectum  or  sigmoid  is  often  denied.  Pathological  examinations  have 
positively  demonstrated  not  only  the  inflammatory  results  of  tubercular 
ulceration,  but  the  presence  of  giant-cells  and  tubercle  bacilli  in  the 
stricture  itself.  The  fact  that  tubercular  ulcerations  of  the  rectum  are 
so  rarely  primary,  and  that  when  they  occur  in  cases  that  have  already 
developed  the  constitutional  disease  they  seldom  heal  before  death  takes 
place,  has  led  many  to  suppose  that  such  a  condition  was  impossible. 

Eecently  the  author  had  the  opportunity  to  examine  the  bodies  of  a 
number  of  patients  who  died  from  tuberculosis,  and  in  four  instances  he 
met  with  undoubted  fibrous  stricture  existing  beneath  well-developed 
tubercular  ulcers;  in  3  of  the  cases  the  stricture  was  in  the  pelvic  colon, 
and  in  the  other  2  within  the  rectum;  one  was  low  down,  and  the  other 
4  inches  from  the  anal  margin.  In  neither  of  the  latter  instances 
had  the  stricture  contracted  to  such  an  extent  as  to  greatly  constrict 
the  gut,  but  in  those  in  the  sigmoid  flexure  the  calibers  had  been 
reduced  to  about  one-fourth  their  normal  size.  Were  the  conclusions 
with  regard  to  the  etiological  influence  of  tuberculosis  in  stricture  to 
rest  upon  these  post-mortem  examinations  alone,  it  would  be  well 
founded;  but  there  is  more:  two  of  these  patients  had  distinct  histories 
of  chronic,  obstinate  constipation  alternating  with  diarrhoea,  discharges 
of  pus  and  mucus,  and  all  the  concomitant  symptoms  of  true  stricture. 
Moreover,  the  histological  examination  of  these  specimens  demonstrated 
the  existence  of  tubercle  bacilli,  giant-cells,  and  embryonic  cells  outside 
the  area  of  the  ulceration. 

In  the  section  upon  Pathology  it  will  also  be  seen  that  the  examina- 
tions of  Mitchell,  Hartmann,  Toupet,  and  others  have  demonstrated 


4Y0  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

these  same  characteristics,  and  thus  proved  beyond  the  shadow  of  a 
doubt  that  tuberculosis  may  result  in  the  formation  of  true  fibrous  stric- 
ture of  the  rectum  without  the  ulcers  having  healed.  This  is  in  har- 
mony with  the  fact  pointed  out  in  the  chapter  on  Tuberculosis  of  the 
Eectum,  that  around  every  tubercular  focus  there  is  a  fibrous  wall 
tending  to  limit  its  extension.  This  fibrous  deposit  which  causes  the 
stricture  is  inflammatory,  but  the  inflammation  is  caused  by  localized 
tuberculosis. 

Syphilitic  Stricture. — For  many  years  the  controversial  war  con- 
cerning the  influence  of  syphilis  in  the  production  of  rectal  strictures  has 
been  waged.  As  far  back  as  1815,  Eicheraud  (Xosographie  chirurgicale, 
t.  iii,  p.  428)  spoke  of  "  condyloma  internis  "  as  a  cause  of  stricture,  and 
from  that  time  onward  the  subject  has  been  more  or  less  constantly  dis- 
cussed in  medical  literature.  ]\Iany  of  the  early  writers,  as  White,  Mor- 
gagni,  S\anes,  Erichsen,  and  Talmann,  failed  to  mention  it  in  their 
writings  upon  stricture;  while  others,  as  Bush,  Copeland,  and  Curling, 
absolutely  denied  its  etiological  significance. 

As  experience  widened  and  observation  became  more  exact,  it  gradu- 
ally became  established  that  a  large  number  of  patients  suffering  from 
stricture  of  the  rectum  had  been  victims  of  syphilis,  or  at  least  venereal 
disease.  At  this  period  we  find  such  men  as  South  (Chelius's  Surgery, 
Am.  ed.,  p.  47),  Lansereaux,  Hamilton,  and  Smith  stating  boldly  their 
opinions  that  syphilis  is  a  cause  of  stricture. 

The  field  of  controversy  then  changed.  Surgeons  generally  admitted 
that  venereal  diseases,  so  frequently  present  in  cases  with  stricture  of 
the  rectum,  must  have  some  influence  in  producing  it.  They  were  un- 
willing to  concede,  however,  that  it  was  through  a  constitutional  pro- 
cess. Thus  we  find  Gosselin  .(Arch.  gen.  de  med.,  1854,  p.  66)  taking  the 
stand  that  the  strictures  in  these  cases  were  never  due  to  constitutional 
syphilis,  but  always  to  a  local  sore,  chancroidal  in  its  nature.  This 
theory  was  adopted  by  a  large  number  of  surgeons,  such  as  Gross,  Van 
Buren,  Bumstead,  ]\Iason,  and  Van  Harlingen.  Mason  published  a 
series  of  31  collected  cases  to  prove  this  theory,  but  of  these  15  had  true 
constitutional  syphilis;  Van  Buren  stated  that,  he  had  seen  chancroidal 
ulcer  followed  immediately  by  stricture  of  the  rectum.  The  facts,  how- 
ever, would  not  sustain  this  theory,  for  the  majority  of  syphilitic  stric- 
tures occurred  from  1  to  4  inches  above  the  anus,  and  chancroids  rarely 
extend  above  the  muco-cutaneous  margin.  The  initial  sore  of  syphilis 
accounted  for  it  no  better,  because  this  was  so  seldom  found  in  the  rec- 
tum at  all.  It  was  finally  referred  to  some  insidious  process  brought 
about  by  the  constitutional  effects  of  this  protean  disease.  This  theory 
was  accepted,  and  at  one  time  became  so  popular  that  every  patient 
suffering  from  stricture  of  the  rectum  was  at  once  pronounced  syphilitic. 


STRICTUEE   OF   THE  RECTUM  471 

whether  there  were  any  other  evidences  of  the  disease  or  not;  but  how 
or  why  it  produced  stricture  was  not  known. 

Fournier  (Lesions  tertiares  de  I'anus  et  rectum,  Paris,  1875)  finally 
advanced  the  theory  that  these  strictures  consisted  in  an  interstitial 
hyperplasia  ending  in  a  fibrous  degeneration  and  persistent  contraction 
of  the  walls  of  the  gut,  to  which  he  applied  the  name  ano-redal  sypliiloma, 
which  has  been  already  discussed.  This  theory  of  Fournier  has  been 
adopted  by  all  syphilographers,  and  is  admitted  by  rectal  surgeons  as 
occurring  occasionally,  but  it  by  no  means  accounts  for  the  large  major- 
ity of  strictures  in  the  syphilitic  which  do  not  conform  to  this  type  of 
the  disease. 

The  question  has  heretofore  been  studied  from  a  clinical  point  of 
view,  and  each  surgeon  has  drawn  his  conclusions  from  the  sequence  of 
symptoms  and  the  unreliable  histories  of  his  patients.  With  better 
knowledge  of  the  pathological  changes  which  occur  in  syphilitic  inflam- 
mations, opinions  are  now  based  upon  the  actual  alterations  in  the 
tissues. 

Microscopic  examination  of  a  sufficient  number  of  these  strictures 
has  been  made  to  prove  positively  that  they  consist  in  the  tissue  changes 
ordinarily  seen  in  secondary  and  tertiary  syphilitic  inflammations,  and 
therefore  it  is  concluded  that  while  syphilis  does  not  occasion  so  many 
strictures  as  was  formerly  supposed,  it  nevertheless  is  accountable  for  a 
considerable  proportion  of  them.  The  question  is  no  longer  "  Does  it 
produce  stricture  ?  "  but  "  "What  is  the  process  by  which  it  does  so  ?  " 

The  writer  has  expressed  his  positive  conviction  that  all  these  stric- 
tures are  preceded  by  ulcerations  (p.  250).  In  order  to  substantiate  this 
opinion  he  must  anticipate  somewhat  his  conclusions  from  the  patho- 
logical studies  of  this  condition.  ]\Iicroscopic  examinations  of  syphi- 
litic stricture  of  the  rectum  show  that  the  condition  consists  in  a 
chronic,  inflammatory  deposit  characterized  by  nodular  or  gummatous 
formations  around  the  blood-vessels  and  distinct  endarteritis.  The 
fibrous  development  or  the  stricture  itself  differs  in  no  other  way  from 
those  strictures  due  to  simple  traumatisms  and  infective  ulceration  of 
the  rectum.  There  has  been  no  histological  examination  of  an  ano- 
rectal syphiloma  in  its  early  stages  so  far  as  is  known.  In  a  somewhat 
extensive  experience  in  rectal  and  genito-urinary  diseases  no  stricture 
of  this  type  has  been  seen  in  which  the  probability  of  previous  ulceration 
of  the  rectal  wall  could  be  eliminated.  All  the  cases  which  have  suf- 
fered from  this  condition  have  either  been  ulcerative  at  the  time,  or  they 
have  given  the  history  of  previous  discharges  of  blood,  mucus,  or  pus 
from  the  rectum,  showing  the  inflammatory  nature  of  the  process. 

The  theory  of  Fournier  was  more  attractive  in  1876  than  it  is  to-day, 
because  at  that  period  local  examination  of  the  rectum  was  much  neg- 


472  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

lected  in  the  secondan-  and  early  tertiary  periods  of  syphilis,  and  there- 
fore the  ulcerations  and  inflammations  of  these  periods  were  overlooked. 
Many  cases  of  syphilis  develop  a  diarrhoea  and  discharge  of  mucus  during 
the  secondary  stages  which  are  generally  attributed  to  the  mercuric  reme- 
dies administered;  whereas  they  are  in  fact  the  result  of  mucous  patches 
or  ulcerative  processes  in  the  rectum  itself.  The  writer  has  demon- 
strated this  fact  more  than  once  to  the  students  at  the  Polyclinic  Hos- 
pital, and  he  believes  that  these  early  lesions  of  secondary  syphilis  are 
always  the  beginning  of  Fournier's  ano-rectal  syphiloma.  Under  the 
influence  of  mercury,  which  every  layman  knows  for  himself  to  be  the 
remedy  for  syphilis,  these  symptoms  disappear,  the  ulcers  in  the  rectum 
heal,  and  the  patient  supposes  himself  to  be  well.  The  discontinuance 
of  treatment,  however,  results  in  the  reestablishment  of  the  pathological 
process  in  the  submucous  tissue  along  the  arteries  and  veins  in  the  shape 
of  minute  gummatous  deposits  around  these  vessels,  and  in  the  muscular 
w^alls  as  an  hypertrophy  of  the  unstriped  muscular  fibers  and  connective- 
tissue  fibers  which  lie  between  them.  Here  there  are  two  distinct  pro- 
cesses; one  a  specific  involvement  that  extends  in  the  line  of  the  blood- 
vessels, the  other  a  purely  inflammatory  condition  that  extends  in  the 
line  of  the  submucous,  muscular^  and  fibrous  tissues.  This  submucous 
inflammation,  set  up  by  the  original  ulcer  and  continued  by  hard  fsecal 
passages  and  the  presence  of  abnormal  gummatous  deposits,  is  really 
the  cause  of  contracture,  and  forms  the  true  fibrous  portion  of  the  stric- 
ture. It  therefore  seems  probable  that  a  very  large  majoritv  of  syphi- 
litic strictures  of  the  rectum  originate  in  some  ulcerative  lesion  of  the 
mucous  membrane  of  the  intestine,  and  that  these  lesions,  due  to  second- 
ary or  tertiary  syphilis,  comprise  most  of  the  so-called  chancroids  which 
were  supposed  at  one  time  to  account  for  so  many  strictures  of  the 
rectum. 

Pathology  of  Stricture. — We  are  indebted  largely  to  Malassez,  Cornil 
(Legons  sur  la  syphilis,  p.  412),  Panas  and  Valtat  (Bull,  de  la  soc.  de 
chir.,  Paris,  1872,  pp.  543,  572),  Hartmann  and  Toupet  (Semaine  medi- 
cale,  1895),  M.  Sourdille  (Quenu  and  Hartmann,  op.  cit.,  pp.  278,  281, 
283),  Jeffries,  and  M.  Girode  for  most  of  our  information  upon  this  por- 
tion of  the  subject. 

In  the  early  stages  of  the  disease  macroscopic  appearances  show  the 
existence  of  an  ulceration  of  the  mucous  membrane  or  a  localized  thick- 
ening. "Whether  ulceration  be  present  or  not,  there  is  always  a  lack  of 
elasticity  in  the  rectal  wall,  a  dense,  leathery  feel,  and  a  decrease  in  the 
distensibility  of  the  organ.  "WTiere  the  ulceration  has  healed,  the  mu- 
cous membrane  is  dry  and  has  lost  its  normal  shining  appearance. 
Quenu  and  Hartmann  state  that  this  condition  is  due  to  the  transfor- 
mation of  the  cylindrical  epithelial  cells  into  the  pavement  variety. 


STRICTURE   OF   THE  RECTUM  4(3 

lu  our  examinations  we  have  not  found  this^  but  rather  a  stratified 
columnar  epithelium  from  which  tlie  goblet-cells  are  absent.  AVliere 
the  ulceration  exists  along  with  the  stricture,  and  there  are  many  cases 
in  which  this  is  the  first  symptom  and  continues  throughout  its  course, 
the  rectum  will  be  filled  with  a  muco-purulent,  sometimes  sanious  dis- 
charge, and  thus  the  dry,  frictional  condition  of  the  mucous  membrane 
will  not  be  observed.  There  is  a  tendency  in  syphilitic  ulceration  to 
heal  in  its  lower  portions  while  it  extends  upward.  The  healed  portion 
appears  as  a  bluish-white  cicatrix,  dense,  hard,  and  almost  ligamentous 
to  the  touch.  The  condition  may  extend  from  the  margin  of  the  anus 
to  the  pelvic  colon,  and  even  sometimes  involve  the  lower  loops  of  this 
portion  of  the  intestine.  Occasionally  the  s}Tnptoms  of  obstruction  will 
be  out  of  proportion  to  the  actual  fibrous  contraction  of  the  intestine. 
In  these  cases  we  have  to  deal  with  the  "  rectitis  prolif  erante  "  of  Hamo- 
nic  (Annal.  med.  chir.  trans.,  France  et  Etrang.,  1886,  vol.  ii,  p.  3).  In 
one  case  observed  by  the  author  the  proliferating  granulations  almost 
entirely  filled  the  rectal  cavity,  obstructing  the  passage  of  faces  and 
causing  an  abundant  purulent  and  bloody  discharge;  after  a  colotomy, 
and  under  specific  and  local  treatment,  they  entirely  disappeared,  but 
left  a  contracted  stricture  of  the  rectum. 

The  fibrous  portion  of  the  stricture  is  not  always  the  narrowest; 
sometimes  the  congestion  and  proliferating  granulation  cause  greater 
narrowing  of  the  canal  than  the  actual  cicatricial  contraction.  "WTiere 
the  ulcer  is  small,  extending  over  a  limited  portion  of  the  circumference 
of  the  intestine,  the  diminution  of  the  caliber  will  be  at  first  propor- 
tionately slight,  and  yet  after  such  ulcerations  as  this  have  healed  the 
circular  fibrous  contraction  may  proceed  and  cause  extensive  strictures, 
not«-ithstanding  the  fact  that  medication  has  controlled  the  s}"philis. 
In  these  cases  the  stricture  possesses  only  the  histological  characteristics 
of  the  infiammatory  type.  As  has  been  frequently  pointed  out,  in  old 
cases,  especially  where  the  stricture  assumes  the  annular  form,  there 
may  be  two  points  of  ulceration,  one  above  the  stricture  and  the  other 
below  it.  That  above  the  stricture  does  not  present  the  character  of  true 
syphilitic  ulceration  even  in  well-marked  s}^hilitic  cases,  but  assumes 
that  of  a  simple  necrotic  ulcer  due  to  the  irritation  and  pressure  of 
fffical  materials  that  lodge  at  that  point.  The  gut  is  always  dilated  and 
the  walls  thinned  above  the  stricture.  The  ulcer  below  is  of  the  type 
that  produces  the  stricture,  whether  it  be  infectious,  syphilitic,  or  tuber- 
cular. The  fact  of  an  ulcer  existing  below  the  stricture  has  been  said  by 
Ball  to  indicate  that  the  stricture  was  caused  through  spasmodic  con- 
traction of  the  circular  fibers,  and  their  consequent  hypertrophy  and 
shortening  due  to  the  efforts  of  the  intestine  to  rid  itself  of  the  irritating 
focus.     This  is  an  ingenious  theory;  it  explains  the  fact  that  while  the 


474 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


mucous  membrane  is  ulcerated  above  and  below  tbe  strictured  area,  that 
over  the  contracted  portion  appears  apparentl}'  normal.  Fistulous  tracts 
are  occasionally  found  beneath  the  mucous  membrane  leading  downward 

from  the  stricture,  and  sometimes 
outside  into  the  perirectal  tissues. 
In  women  these  fistulas  may  break 
into  the  vagina,  thus  occasioning 
recto-vaginal  fistula  (Fig.  166); 
they  sometimes  pass  through  the 
sphincter  muscles  or  outside  of 
them,  causing  blind  internal,  or 
even  complete,  fistula.  Upon  the 
level  of  the  stricture  itself,  espe- 
cially where  it  is  of  the  annular 
variety,  the  mucous  membrane 
may  not  appear  to  the  eye  to  be 
at  all  altered.  An  examination 
with  the  finger,  however,  shows 
that  it  fails  to  move  over  the  sub- 
jacent tissues,  that  it  is  smooth 
and  frictional  to  the  touch,  and 
appears  to  be  amalgamated  with 
the  tissues  beneath  it.  Thus  we 
have,  as  Malassez  pointed  out,  three  positive  conditions  or  locations 
to  study  in  the  pathological  examinations:  the  stricture  itself,  the 
parts  above,  and  those  below  it.  Hartmann  and  Toupet  have  studied 
this  subject  very  thoroughly  following  these  lines.  One  constant  fea- 
ture in  all  the  varieties  of  stricture  which  they  describe  is  the  absence 
of  ulceration  at  the  level  of  the  stricture  and  the  substitution  of  pave- 
ment epithelium  with  papillae  for  the  cylindrical  epithelium  with  glands. 
The  alteration  they  say  is  complete,  and  occurs  in  all  strictures,  whether 
due  to  syphilitic,  tubercular,  or  infective  inflammations.  This  substi- 
tution they  also  find  in  chronic  catarrhal  proctitis,  a  fact  which  is  sig- 
nificant in  indicating  the  inflammatory  nature  of  strictures,  although 
due  to  specific  causes.  Quenu  and  Hartmann  (op.  cit.,  p.  262)  record 
the  case  of  stricture  of  the  rectum  in  which  this  substitution  of  the 
pavement  for  the  cylindrical  epithelium  went  on  to  such  an  extent  that 
a  true  pachydermatous  condition  of  the  mucous  membrane  of  the  rectum 
was  established. 

Malassez  says:  "Just  above  the  time  stricture  the  tissue  is  formed  of 
new  elements,  is  verj^  vascular,  and  offers  little  resistance  to  the  passage  of 
instruments;  this  part  of  the  stricture  is  narrower  than  the  true  connec- 
tive-tissue portion  on  account  of  the  increased  circulation  and  cellular 


Fig.  166. — Stricture  complicated  by  Recto- 
vaginal Fistula. 


STRICTUEE   OF  THE  RECTUM  475 

infiltration."  Lo\rer  do-^-n  in  the  widest  part  of  the  stricture  there  are 
fascicles  of  hard  connective  tissue  surrounded  by  embryonic  cells  ^rhich 
present  the  characteristics  of  true  cicatricial  tissue;  sometimes  the  whole 
rectal  wall  is  involved  in  the  sclerous  process^,  and  sometimes  only  the 
internal  layers.  Even  the  circular  muscular  layer  may  be  invaded  while 
the  longitudinal  layer  is  uninvolved  and  separated  from  the  other  by  a 
sort  of  callous  infiltration.  Hartmann  and  Toupet  say  that  when  the 
entire  thickness  of  the  rectal  wall  has  been  involved,  there  may  form 
around  it  a  sort  of  "  callous  fibro-lipomatous ''  mass.  In  one  case  in 
which  they  made  a  histological  examination  of  the  stricture  removed, 
the  whole  mass  was  composed  of  fatty  cells  dissected  by  fibrous  bands 
and  ramifying  blood-vessels  with  hj-pertrophy  of  the  walls,  thickness 
of  the  intima,  and  reduced  caliber.  The  external  coats  were  separated 
by  small  round  cells,  the  nuclei  of  which  were  easily  stained.  Here 
we  have  no  evidence  of  syphilis  or  tuberculosis,  but  simply  a  type  of 
inflammatory  infiltration.  In  another  case,  however,  presenting  prac- 
tically the  same  pathological  changes  in  other  respects,  they  have  dem- 
onstrated the  existence  of  typical  s}^hilitic  endarteritis  and  small  gum- 
matous deposits  all  along  the  course  of  the  arteries  and  veins.  In  both 
of  these  cases  the  blood-vessels  are  encroached  upon  until  they  are  prac- 
tically occluded  at  certain  points.  In  the  fibrous  tissue  there  appear  at 
places  certain  new  blood-vessels,  but  this  collateral  circulation  is  not 
constant.  The  features  which  were  always  present  in  syphilitic  stricture 
are  endarteritis  and  the  small  nodular  developments  about  the  arteries, 
which  are  gummatous  in  their  nature,  some  of  them  seeming  to  have 
softened  doT\Ti  in  the  center.  The  nodules  are  not  so  constantly  situated 
around  the  veins  as  around  the  arteries,  but  they  also  occur  in  this 
location. 

In  tubercular  stricture  one  finds  a  different  condition  of  affairs. 
Ordinarily  the  entire  epithelial  surface  of  the  mucous  membrane  will 
be  found  destroyed.  Quenu  and  Hartmann  state  that  the  epithelium 
destroyed  is  replaced  by  the  pavement-striated  variety.  The  examina- 
tions made  for  the  author  by  Heitzmann  and  Jeffries  do  not  demonstrate 
any  such  substitution  in  these  cases.  They  show  that  the  epithelium  has 
entirely  disappeared.  The  inflammatory  infiltration  extends  considerably 
beyond  the  ulceration.  Upon  the  mucous  membrane  a  number  of  papillae  , 
are  seen,  and  in  the  submucosa  in  the  infiltrating  fibrous  tissue  there 
are  here  and  there  tuberculous  follicles  which  show  a  tendency  to  caseous 
degeneration.  The  blood-vessels  are  crowded  and  somewhat  occluded; 
they  are  diminished  in  number,  but  they  show  no  alteration  in  their 
walls.  Hartmann  and  Toupet  state  that  in  50  preparations  they  were 
able  to  find  only  2  in  which  they  could  demonstrate  the  existence  of 
an  arteriole  in  the  deep  mucosa,  and  in  this  they  perceived  no  appreciable 


476  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

alterations.     There  were  numerous  capillaries,  however,  the  lumens  of 
which  were  quite  narrow. 

The  following  report  on  a  case  observed  by  the  author  corroborates 
the  above  observations,  with  the  exception  of  the  substitution  of  pave- 
ment for  cylindrical  epithelium: 

Syphilitic  Stricture  of  tlie  Rectum — Histological  Examination 
hi/  F.  M.  Jeffries 

Six  inches  above  the  anus  a  stricture  is  presented.  At  this  point  the  lumen  of 
the  gut  is  greatly  diminished  so  as  to  hardly  admit  the  passage  of  a  probe  the  size 
of  a  lead-pencil.  It  is  tortuous,  and  numerous  crypts  and  pockets  beset  its  course. 
The  walls  here  are  generally  thickened. 

Above  the  stricture  the  colon  wall  is  thin  and  distended  and  the  gut  is 
engorged  with  faeces.  Here  again  are  numerous  saccular  diverticuli  and  pockets  of 
all  sizes.  Just  above  the  stricture  are  two  which  are  the  size  of  hens'  eggs.  In 
addition  are  numerous  small  saccular  pockets  the  size  of  a  pea  which  are  filled 
with  faeces  and  are  noticeable  only  from  the  outside.  Viewed  from  the  inside,  the 
sites  of  these  pockets  are  hardly  apparent,  but  upon  close  inspection  it  appears 
that  they  are  at  the  sites  of  solitary  follicles.  The  follicle  has  disappeared  and  a 
small  channel  has  taken  its  place,  giving  communication  between  the  sac  cavity 
and  the  lumen  of  the  gut.  Macroscopic  examination  of  these  sacs  gives  the 
impression  that  the  peritonaeum  constitutes  the  sole  barrier  between  the  contents 
and  the  peritoneal  cavity.  Microscopically,  however,  the  inner  surface  is  lined 
with  a  pyogenic  membrane. 

Throughout  the  extent  of  the  large  intestine  are  eight  or  ten  small  ulcers,  and 
in  the  caecum  is  a  large  ulcer  which  presents  the  appearance  of  a  union  of  two 
ulcers.  At  this  point  the  walls  are  thickened  and  puckered  in  such  a  manner  as 
to  markedly  distort  the  contour  of  the  gut. 

The  ulcers  are  of  fairly  uniform  size  and  appearance,  averaging  1.5  by  2.5  centi- 
meters in  diameter.  The  long  diameter  of  all  of  them  is  transverse  to  the  axis  of 
the  intestine.  (This  is  the  course  of  the  blood-vessels  at  this  part.)  Their  edges 
are  abrupt  and  rough,  and  the  mucosa  turns  downward  and  underneath.  The 
floors  are  rough  and  present  slight  elevations  and  depressions.  The  intestinal  wall 
around  and  beneath  the  ulcers  is  thickened  and  indurated. 

Beneath  the  peritonaeum  are  numerous  small  miliary  elevations  which  thickly 
beset  the  indurated  tissue.     Microscopically  these  are  found  to  be  gummata. 

At  the  site  of  the  stricture  there  is  no  sign  of  inflammation  either  in  the  mucosa 
or  the  remaining  coats.  There  is  a  marked  hypertrophy  of  the  inner  and  outer 
muscular  coats,  and  associated  with  this  change  is  an  increase  of  fibrous  tissue 
confined  largely  to  the  external  muscular  coat.  The  submucosa  is  closely  studded 
with  blood-vessels  most  of  which  present  thickened  walls. 

Microscopical  examination  of  the  tissues  of  the  edge  of  one  of  the  ulcers 
resulted  as  follows: 

Acute  inflammation  manifested  by  an  exudative  infiltration  pervades  the  entire 
thickness  of  the  intestinal  wall  from  the  mucosa  to  the  peritonaeum.  The  infiltra- 
tion is  of  the  small  round-celled  variety  and  is  most  marked  in  the  muscular  coats 
and  the  submucosa.  The  arteries  throughout  are  increased  in  numbers  and  present 
thickened  walls,  in  some  cases  with  obliterated  lumina.     The  thickening  is  con- 


STRICTURE   OF   THE  RECTUM  4TY 

fiaed  largely  to  the  intima,  and  in  many  instances  there  appears  to  be  an  exfolia- 
tion of  endothelial  cells  which  are  embedded  within  the  mass  of  blood-corpuscles. 
These  cells  are  somewhat  swollen,  but  exhibit  no  further  degenerative  change  and 
stain  nicely. 

The  intestinal  wall  is  thickened,  the  increase  largely  confined  to  the  sub- 
mucosa.  This  is  due  in  part  to  fibrous  tissue,  but  principally  to  the  fact  that  it  is 
thickly  beset  with  gummata  most  of  which  are  miliary  in  character. 

One  large  gumma  3.20  centimeters  by  1.76  centimeters  (1|  by  f  inch)  in 
diameter  is  situated  just  beneath  the  ulcer;  another,  external  to  the  muscular 
coats,  is  1.60  centimeters  by  2.80  centimeters  (|-  by  1^  inch)  in  diameter. 

A  few  giant-cells  are  found.  These  are  rich  in  nuclei,  the  latter  being  scattered 
irregularly  throughout  the  protoplasm  of  the  cell. 

The  mucosa  adjacent  to  the  ulcer  exhibits  the  small  round-celled  infiltration  of 
acute  inflammation.  The  epithelium  of  the  villi  is  desquamated,  lut  that  of  the 
crypts  of  Lieberhiihn  is  intact.  At  the  edge  of  the  ulcer  the  mucosa  abruptly  ends, 
leaving  but  a  thin  layer  of  the  deepest  strata,  including  the  ends  of  two  or  three 
crypts,  forming  the  floor  of  the  ulcer.  The  muscularis  mucosae  remains  intact 
throughout. 

The  smaller  gummata  are  made  up  of  aggregations  of  small  round  and  epithelioid 
cells  which  are  somewhat  loosely  connected  and  present  an  appearance  suggesting 
a  more  or  less  fluid  intercellular  substance.  The  outer  zone  of  these  nodules  is 
made  up  of  the  usual  small  round  cells  with  a  few  fibers  of  connective  tissue  inter- 
mmgling  and  rather  numerous  blood-vessels,  some  of  which  extend  to  the  inte- 
rior. Within  this  outer  zone  giant-cells  are  occasionally  seen.  In  some  of  these 
nodules  necrotic  changes  have  occurred,  and  their  centers  present  an  appearance 
resemblmg  cheesy  degeneration  wherein  no  nuclei  are  manifest. 

The  two  larger  gummata  difier  so  in  their  structure  that  they  will  be  described 
separately. 

The  larger,  situated  in  the  submucosa,  is  surrounded  entirely  by  fibrous  tissue, 
though  it  is  scant  in  some  portions.  Within  the  fibrous  coat  is  a  thin  layer  of 
small  round  cells,  embedded  in  which  are  numerous  capillary  blood-vessels  and 
one  or  two  large  giant-cells.  A  few  connective-tissue  fibers  are  also  found  and 
they  are  more  abundant  m  the  margin  toward  the  center. 

The  greater  part  of  the  nodule  is  made  up  of  necrotic  substance  thickly  beset 
with  nuclei,  most  of  which  are  fragmentary,  the  fragments  of  each  nucleus  remain- 
ing grouped  in  close  apposition. 

The  remaining  nodule  is  situated  external  to  the  muscular  coat  and  is  sur- 
rounded by  a  fibrous  capsule  which  is  thicker  than  the  one  just  described.  Within 
this  fibrous  coat,  sharply  defined  from  it,  is  a  thicker  layer  of  epithelioid  cells, 
spindle-shaped  and  round,  and  with  large  intercellular  spaces.  This  layer  is  devoid 
of  blood-vessels  and  presents  one  or  two  giant-cells.  The  interior  is  a  necrotic 
mass  resembling  complete  cheesy  degeneration,  and  contains  minute  fragments  of 
nuclei  only,  except  at  its  periphery,  where  a  few  larger  fragments  are  seen. 

A  succinct  statement  of  the  differences  in  the  pathology  of  the  three 
typical  varieties  of  inflammatory  strictures  will  be  found  in  the  fol- 
lowing table,  which  is  briefly  summarized  from  the  works  of  Toupet, 
Jeffries,  Mitchell,  Malassez,  Hartmann,  and  Sourdille: 


478 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


Simple  Inflammatory 
Stricture 

The  destruction  of  the 
cylindrical  epithelial  layer 
and  the  sulistitution  of 
the  same  by  striated  pave- 
ment epithelium.  (Found 
only  by  French  patholo- 
gists.) Diffuse  sclerosis  of 
the  submucosa  with  amal- 
gamation of  all  the  coats 
of  the  bowel,  excepting, 
perhaps,  the  external  mus- 
cular layer.  Decrease  in 
the  number  of  blood-ves- 
sels, but  no  marked 
changes  in  the  arterial 
walls.  Occasionally  cal- 
careous deposits  or  fibro- 
lipomatous infiltration 
around  the  outside  of  tlie 
walls. 


Syphilitic 

On  the  level  of  the 
stricture  the  mucous  mem- 
brane may  be  absolutely 
destroyed  and  replaced  by 
true  cicatricial  tissue,  or 
the  inflammatory  process 
having  been  due  to  spe- 
cific inflammation  without 
great  destruction  of  tissue, 
the  mucous  membrane  is 
reformed  over  the  stric- 
tured  portion.  In  such 
cases  we  have  still  the 
substitution  of  the  pave- 
ment for  the  cylindrical 
epithelium  (Hartmann  and 
Toupet).  The  sclerous  or 
flbrous  degeneration  of  the 
submucosa  and  muscular 
walls  of  the  gut  is  homo- 
geneous throughout.  The 
blood-vessels  show  infiltra- 
tion of  all  their  walls  with 
distinct  thickening  of  the 
endothelium,  narrowing  of 
the  caliber,  and  all  the 
evidences  of  specific  end- 
arteritis. Around  both 
the  arteries  and  veins  are 
gummatous  nodules  with 
clearly  defined  outlines, 
some  of  which  present  evi- 
dences of  softening  in  the 
center. 

Ricder  states  (Annales 
de  path.,  1898,  p.  545)  that 
sometimes  the  submucosa 
exists  only  as  a  thin  con- 
nective tissue  and  cellular 
layer  with  miliary  gum- 
mata  scattered  throughout 
it,  and  that  the  walls  of 
the  veins  alone  may  be  in- 
volved, the  arteries  re- 
maining normal.  These 
statements  have  not  been 
corroborated. 

It  is  by  no  means  so  easy  to  distinguish  these  varieties,  even  with 
the  microscope,  as  it  would  seem  from  the  above.     A  chronic  inflamma- 


Tubercular 

The  epithelium  and  the 
superficial  mucosa  may  be 
entirely  destroyed  and  the 
whole  strictured  surface 
ulcerated.  Where  the 
mucous  membrane  cover- 
ing the  strictured  portion 
remains  intact,  the  colum- 
nar epithelium  is  trans- 
formed or  replaced  by 
the  pavement  epithelium 
(Hartmann  and  Touiic-t). 
Fibrous  bands  more  or 
less  dense  extend  through- 
out the  submucosa.  These 
bands  are  separated  here 
and  there  by  tuberculous 
follicles.  The  blood-ves- 
sels themselves  are  only 
altered  in  their  external 
walls  by  infiltration  with 
embryonic  round  cells. 
Giant -cells  exist  in  the 
more  superficial  portions 
of  the  fibrous  tissues, 
gradually  decreasing  as 
one  extends  outward  from 
the  caliber  of  the  gut. 

Tubercle  bacilli  are 
found  in  the  granulations, 
but  disappear  altogether 
in  the  sclerous  portion. 


STRICTURE  OF  THE  RECTUM  479 

tory  condition  with  endarteritis  is  ordinarily  considered  as  an  evidence 
of  constitutional  syphilis,  but  endarteritis  has  been  known  to  exist  in 
inflammations  due  to  traumatism  and  caustic  substances.  It  is  not  justi- 
fiable, therefore,  to  base  a  diagnosis  of  syphilitic  stricture  upon  the 
existence  of  this  condition  alone.  We  must  have  other  evidences  of 
the  disease  in  the  shape  of  gummatous  nodules  in  the  strictured  area, 
and  at  least  a  suspicion  of  the  disease  in  the  patient.  A  simple,  diffuse, 
inflammatory  stricture  may  become  infected  with  tubercle  bacilli,  and 
yet  not  be  a  tubercular  stricture.  The  finding  of  the  bacillus  is  not 
sufficient  evidence  upon  which  to  base  a  diagnosis  of  true  tubercular 
stricture;  in  addition  to  this  evidence  one  must  have  at  least  the  pres- 
ence of  giant-cells  with  embryonic  infiltrations  of  the  perivascular  re- 
gion, and  tubercular  nodules  with  well-defined  limitations.  These  con- 
ditions may  thus  be  so  combined  that  it  is  very  diffievilt  to  determine 
the  exact  nature  of  a  stricture  even  after  it  has  been  excised  and  a 
thorough  histological  examination  made.  ^AHiere  the  patient  has  a  his- 
tory of  tuberculosis  or  syphilis,  one  may  presume  upon  the  possibility 
of  the  stricture  partaking  of  the  nature  of  the  general  disease;  but 
he  must  always  bear  in  mind  that  a  syphilitic  or  a  tuberculous  individual 
may  be  afflicted  with  a  simple  inflammatory  stricture. 

Etiologij. — Diffuse  inflammation  of  the  intestinal  walls  is  undoubt- 
edly the  chief  etiological  factor  in  the  production  of  stricture.  Trau- 
matism, infection,  syphilis,  tuberculosis,  and  dysentery  may  all  be  the 
exciting  causes.  In  313  collected  cases,  216  occurred  in  women;  this 
preponderance  of  the  disease  in  that  sex  has  been  the  strongest  argu- 
jnent  against  syphilis  being  the  chief  cause  of  stricture,  for  while  women 
suffer  very  much  more  frequently  from  the  latter  than  men,  men  suffer 
very  much  more  frequently  from  constitutional  syphilis  than  women. 
This  might  be  explained  were  it  admitted  that  stricture  of  the  rectum  is 
frequently  due  to  the  initial  lesions  of  syphilis  or  to  chancroid,  but  as 
has  been  already  shown,  this  is  not  the  case,  and  the  more  frequent 
occurrence  of  these  lesions  about  the  anus  in  women  will  not  account 
for  the  preponderance  of  stricture  in  this  sex. 

The  close  proximity  of  the  rectum  to  the  genital  organs  in  women 
constantly  subjects  it  to  injury  during  childbirth  and  pressure  from  the 
gravid  or  displaced  uterus;  constipation  is  also  very  much  more  frequent 
in  women  than  in  men,  thus  subjecting  the  mucous  membrane  to  more 
frequent  lesions  from  this  source.  It  does  not  seem  difficult,  therefore, 
to  explain  why  strictures  are  more  frequent  in  this  sex,  especially  if 
we  concede  the  fact  that  the  majority  of  strictures  have  their  origin  in 
some  lesion  of  the  mucous  membrane  or  some  traumatism  to  the  wall 
of  the  gut. 

Wallis  (Brit.  Med.  Jour.,  1900,  vol.  ii,  p.  1002),  who  has  seen  a  num- 


480  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

ber  of  these  eases,  states  that  in  liis  opinion  most  rectal  strictures  are  due 
to  septic  ulceration  or  to  the  pressure  of  the  child's  head  during  labor. 
Fulton  (Kansas  City  Med.  Jour.,  1894,  p.  181)  reports  a  very  positive  case 
in  which  the  stricture  followed  prolonged  pressure  of  the  child's  head 
in  the  hollow  of  the  sacrum.  Duplay  (Semaine  medicale,  1892,  p.  461) 
states  that  strictures  of  the  rectum  differ  in  no  wise  from  those  affecting 
the  urethra  and  the  oesophagus,  and  that  they  are  all  due  to  inflamma- 
tory processes,  the  causes  of  which  may  be  simple  infection,  traumatism, 
syphilis,  tuberculosis,  or  any  other  condition  which  produces  a  rectitis 
with  cellular  infiltration.  Syphilis,  as  we  have  already  seen  and  ad- 
mitted, has  an  undoubted  etiological  influence  in  the  production  of  the 
disease.  The  fact,  however,  that  the  large  majority  of  strictures  show 
no  amelioration  from  antispecific  treatment,  demonstrates  very  clearly 
that  in  these  cases  there  is  another  factor.  If  the  stricture  were  due 
to  gummata  and  syphilitic  cellular  infiltration  alone,  the  specific  medi- 
cation would  undoubtedly  produce  an  amelioration  of  the  symptoms. 
In  conclusion  it  may  be  said  that  the  fact  of  a  patient's  having  had 
S3^philis  does  not  prove  that  a  subsequent  stricture  of  the  rectum  is 
due  to  this  cause;  the  syphilitic  may  have  non-syphilitic  stricture. 

Tuberculosis  is  not  duly  appreciated  as  a  cause  of  stricture.  Refer- 
ence has  been  made  in  a  former  chapter  to  the  development  of  dense 
connective-tissue  walls  around  tubercular  fistulas  and  ulcers,  so  it  is  not 
surprising  to  find  pathologists  claim  to  have  demonstrated  beyond  the 
question  of  a  doubt  that  tubercular  inflanmiation  is  the  exciting  cause 
of  a  certain  number  of  strictures  of  the  rectum.  In  the  specimen 
(Fig.  90)  we  have  to  deal  not  only  with  a  tubercular  ulceration  but 
also  a  fistula  and  a  stricture  of  the  rectum  combined.  Tubercle  bacilli 
and  giant-cells,  together  with  embryonic  infiltration,  were  found  in  the 
inner  layers  of  the  stricture  with  pure  fibrous  tissue  in  the  outer  layers. 
RoUeston  (Transactions  of  the  Path.  Soc.  of  London,  1890,  p.  131)  re- 
ports 3  cases  of  stricture  of  the  large  intestine  due  to  tubercular  deposit, 
1  of  which  was  in  the  sigmoid  flexure.  In  the  post-mortem  room  at  the 
Almshouse  Hospital  of  this  city,  the  author  has  demonstrated  no  less 
than  five  strictures  of  the  rectum  and  sigmoid  in  patients  who  died 
from  general  tuberculosis;  the  strictures  all  showed  the  embryonic  infil- 
tration, giant-cells,  and  tubercle  bacilli.  This  disease  is  therefore  un- 
doubtedly the  cause  of  certain  strictures. 

In  the  section  upon  dysenteric  inflammation  of  the  rectum  and 
sigmoid,  it  was  stated  upon  good  authority  that  many  of  the  specific 
ulcerations  occur  in  the  sigmoid  flexvire  and  in  the  rectum.  Wherever 
ulceration  occurs  the  possibilities  of  infection,  hyperplasia,  and  fibrous 
contraction  are  always  present.  ^Mathews,  basing  his  conclusions  upon 
personal  experience  and  the  pathological  studies  of  Ouchterloney,  states 


STRICTURE   OP   THE   RECTUM  481 

very  positively  that  dj^sentery  never  produces  stricture  of  the  rectum. 
He  has  many  followers  in  this  opinion,  among  them  Cornil,  and  "Wood- 
ward, who  in  his  history  of  the  War  of  the  Eebellion  found  no  case  of 
such  a  stricture  either  in  the  hospitals  or  upon  the  pension  rolls.  On 
the  other  hand  Gibbs,  Allingham,  Kelsey,  Cripps,  and  Castex  all  affirm 
just  as  positively  that  they  have  seen  cases  which  dated  from  distinct 
attacks  of  dysentery;  the  author  has  seen  2  cases  in  which  the  patients 
ascribed  the  condition  to  attacks  of  dysentery,  but  in  these  the  only 
proof  of  the  disease  consisted  in  the  fact  that  they  had  suffered  from 
pain  and  burning  in  the  rectum,  tenesmus,  diarrhcea,  and  the  discharge 
of  blood  and  mucus,  and  such  symptoms  may  be  due  to  any  inflam- 
matory condition  of  the  lower  end  of  the  intestinal  canal.  While  it 
is  probable  that  these  patients  did  suffer  from  dysentery,  inasmuch  as 
they  both  came  from  Southern  States  in  which  the  disease  is  very  preva- 
lent, and  where  the  inhabitants  are  quite  familiar  with  it,  it  is  impos- 
sible to  say  positively  that  either  of  the  strictures  resulted  from  the 
dysentery  itself.  Certainly  no  case  has  thus  far  been  discovered  in  which 
any  of  the  typical  bacteria  to  which  dysentery  has  been  ascribed  have 
been  found  in  the  strictured  area.  Wliile,  therefore,  the  possibility  and 
even  the  probability  of  dysenteric  stricture  is  conceded,  it  must  be 
admitted  that  the  condition  is  not  absolutely  proved. 

Irritating  injections,  habitual  constipation,  and  pgederasty  have  been 
mentioned  as  causes  leading  to  rectal  inflammation,  ulceration,  and  sub- 
sequent stricture.  In  the  Medical  and  Surgical  History  of  the  War 
there  are  4  cases  of  stricture  of  the  rectum  reported  as  resulting  from 
gunshot  wounds  of  this  organ.  In  2  other  cases  death  occurred  from 
the  wound,  but  not  until  after  a  strictured  condition  had  been  discov- 
ered. Any  cause,  therefore,  which  results  in  the  destruction  of  tissue, 
in  inflammation  of  the  submucosa,  or  the  deeper  tunics  of  the  rectal 
or  intestinal  wall,  may  bring  about  a  stricture. 

Symptoms. — The  symptoms  of  stricture  may  be  divided  into  those 
of  the  latent,  the  ulcerative  or  inflammatory,  and  the  obstructive  periods. 

Latent  Period. — A  certain  number  of  classical  writers  deny  or  ignore 
this  period  entirely  (Quenu  and  Hartmann,  vol.  vi,  p.  297;  Kelsey,  p. 
350;  Allingham,  p.  323;  and  Cripps,  p.  235).  In  stricture  due  to  malig- 
nant neoplasms  the  disease  may  exist  for  long  periods  before  any  marked 
symptoms  will  be  noticed.  There  is  also  a  latent  period  in  strictures 
due  to  inflanmiatory  conditions,  either  simple  or  specific.  An  injury 
occurs  to  the  rectal  wall  through  pressure  of  the  head  during  labor, 
through  surgical  procedures  or  foreign  bodies,  and  a  small  ulceration 
may  develop  which  goes  on  for  a  certain  length  of  time  and  finally  heals. 
From  this  time  forward  the  patient  has  no  symptoms  of  rectal  disease 
until  months  afterward  he  begins  to  notice  increasing  difficulty  at  stool, 
31 


482  THE  ANUS.  RECTUM,  AND  PELVIC  COLON 

and  an  examination  shows  a  well-developed  stricture  constricting  the 
caliber  of  the  gut  to  a  greater  or  less  degree.  This  latent  period  is 
very  common  in  syphilitic  strictures  and  those  following  surgical  opera- 
tions. It  is  well  illustrated  in  the  case  quoted  from  Cripps  (p.  233), 
and  in  the  stricture  of  large  caliber  described  in  the  early  part  of  this 
chapter.  It  also  occurs  in  cases  due  to  perirectal  inflammations  and 
pelvic  cellulitis.  In  all  these  conditions  the  rectal  symptoms  in  the  be- 
ginning are  entirely  subordinate  to  those  of  the  primary  condition,  and 
after  the  real  cause  of  the  stricture  has  been  alleviated  or  removed  there 
is  a  period  in  which  the  rectal  symptoms  are  absent.  It  is  that  period 
between  the  acute  inflammatory  process  and  the  time  when  the  fibrous 
bands  begin  to  obstruct  the  caliber  of  the  gut  by  persistent  contraction, 
■which  is  called  the  "  latent  period,"  and  in  which  no  definite  s}anptoms 
occur. 

The  ampulla  of  the  rectum  is  a  very  wide  and  distensible  cavity, 
and  it  requires  a  considerable  amount  of  constriction  to  develop  symp- 
toms of  obstruction  in  it.  Until  this  degree  of  contraction  has  been 
developed,  therefore,  the  SA^mptoms  of  stricture  may  not  manifest  them- 
selves at  all.  The  symptoms  of  the  latent  period  may  be  elicited  by 
careful  interrogation.  The  patient  will  generally  admit  that  for  con- 
siderable periods  of  time,  or  even  dating  the  period  back  to  that  of 
the  original  disease,  he  has  suffered  more  or  less  distinctly  from 
heaviness,  weight  or  aching  in  the  rectum  or  sacral  region,  and  pains 
shooting  do-wn  the  legs.  Dysuria  or  frequent  urination  of  a  mild  degree 
is  often  noticed  at  this  time,  and  patients  so  affected  have  been  treated 
for  cystitis,  urethritis,  and  stricture  of  the  urethra,  whereas  the  actual 
disease  Avas  in  the  rectum.  Eeflex  disturbances  of  the  uterine  append- 
ages, the  digestive  organs,  and  of  the  nervous  system  also  occur  in  this 
period.  It  is  well,  therefore,  to  bear  in  mind  its  possibilities  whenever 
there  are  obscure  symptoms  in  patients  who  have  suffered  from  rectal 
ulceration,  pelvic  cellulitis,  uterine  displacements,  tuberculosis,  or  syphi- 
lis, and  to  examine  from  time  to  time  to  determine  the  possible  devel- 
opment of  stricture. 

Ulcerative  or  Inflammatory  Stage. — The  symptoms  of  the  ulcerative 
period  previous  to  the  formation  of  stricture  differ  in  no  wise  from 
those  described  in  the  chapter  upon  General  Ulceration  of  the  Rectum. 
They  consist  in  dull,  constant  pain  in  the  perinajum  or  sacral  region, 
diarrhoea,  tenesmus,  discharges  of  mucus,  blood,  and  pus,  together  with 
reflex  disturbances  of  the  genito-urinary  and  digestive  organs. 

These  SAonptoms  may  entirely  disappear  and  the  patient  feel  per- 
fectly well  during  the  latent  period  of  stricture  formation,  or  they  may 
pass  gradually  into  those  of  stricture  before  the  ulceration  heals.  As 
the  causative  ulceration  heals,  or  the  inflammatory  tissue  begins  to  con- 


STRICTURE   OF   THE  RECTUM  483 

tract,  the  symptoms  of  diarrhoea  subside,  and  difficulty  in  obtaining  a 
movement  grows  more  and  more  marked.  At  this  period  the  reflex 
disturbances  of  the  genito-urinary  organs  will  increase,  the  rectal  dis- 
charges will  grow  less,  and  while  there  will  be  tenesmus  and  frequent 
desire  to  go  to.  stool,  the  act  can  only  be  accomplished  with  great 
straining. 

Obstructive  Period. — The  symptoms  of  this  period  are  the  typical 
signs  of  the  disease.  They  consist  in  gradually  increasing  and  per- 
sistent constipation;  from  a  simple  irregularity  the  movements  of  the 
bowels  gradually  become  less  and  less  easy,  until  a  faecal  passage  is  not 
only  a  rarity  but  a  real  travail.  Patients  go  one,  two,  five,  ten,  and 
even  thirty-six  days  without  having  a  movement,  and  then  after  strain- 
ing, employing  injections  and  instruments  for  breaking  down  the  mass, 
a  fsecal  explosion  occurs,  the  intestines  are  cleaned  out,  and  for  another 
period  they  may  be  comparatively  comfortable.  One  of  the  writer's 
patients  devoted  the  Sabbath  day  to  the  movement  of  his  bowels.  The 
process  required  about  two-thirds  of  the  day,  and  recovery  from  the 
exhaustion  occasioned  by  it  took  up  the  rest. 

Godebert  (Theses,  Paris,  1873,  ISTo.  496)  relates  a  case  in  which  the 
movement  of  the  bowels  only  occurred  once  in  a  month  or  six  weeks. 
It  was  then  a  veritable  labor:  purgatives  had  no  effect;  the  stomach  was 
much  swollen,  the  appetite  was  lost,  and  the  respirations  very  short. 
When  the  symptoms  became  so  severe  that  the  patient  could  bear  them 
no  longer,  she  retired  to  her  chamber  and  with  the  finger  introduced 
into  the  vagina,  and  straining  with  all  her  might,  she  was  able  to  relieve 
herself  little  by  little  of  the  accumulated  mass.  The  operation  required 
the  greater  part  of  a  day;  the  faeces  at  first  were  extremely  hard  and  dry, 
but  the  later  portion  of  the  movement  was  soft  and  liquid. 

The  constipation  in  such  cases  is  mechanical;  it  is  an  obstipation  due 
to  arrest  of  the  fsecal  matter  above  the  stricture.  This  arrest  often 
results  in  irritation  of  the  mucous  membrane  and  increased  secretion. 
Diarrhoea  may  therefore  alternate  with  constipation,  but  what  is  more 
frequently  the  case,  the  patient  suffers  from  a  diarrhoea  and  constipation 
at  the  same  time.  There  is  a  frequent  discharge  of  mucus  and  semi- 
fluid matter,  while  there  still  remains  above  the  stricture  large  masses 
of  hard  fsecal  matter.  This  condition  is  comparable  to  the  dribbling 
of  urine  in  enlarged  prostates,  in  which  the  patient  supposes  that  he 
suffers  from  incontinence  when  really  it  is  from  inability  to  empty  his 
bladder.  One  must  not  always  conclude  that  the  bowels  are  being  thor- 
oughly emptied  because  of  frequent  diarrhoeal  movements.  The  tempta- 
tion to  give  opium  or  astringents  in  order  to  control  such  a  diarrhoea 
should  never  be  yielded  to  until  one  is  absolutely  sure  that  there  is  no 
accumulation  of  fseces  above  the  strictured  part. 


484 


THE  AXUS,  RECTUM,   AND   PELVIC   COLON 


Constipation,  it  should  be  remembered  also,  is  a  comparative  term. 
Some  require  movements  every  day,  while  others  equally  as  healthy  re- 
quire them  only  once  in  a  week  or  more,  as  was  the  case  in  a  patient 
who  for  forty  years  had  a  movement  every  Saturday  night,  and  died 
from  pneumonia  at  the  ripe  age  of  ninety-five  years.  Gradually  increas- 
ing constipation,  together  with  greater  and  greater  effort  to  relieve  one's 
self,  are  much  more  important  symptoms  than  infrequent  passages. 
With  this  one  observes  abdominal  distention  and  accumulation  of  hard 
faecal  masses  in  the  intestine;  above  the  brim  of  the  pelvis,  and  all 
over  the  abdomen,  in  fact,  one  may  frequently  feel  hard,  lumpy  iseces 


Fig.  I'jT. — STnicTUEE  of  the  RECTrji  CAUsrsG  PROciDE>-nA. 


through  the  distended  abdominal  wall.  It  is  to  these  masses  that  is  due 
the  greatest  danger  in  the  disease.  Stricture  rarely  if  ever  obliterates 
the  lumen  of  the  gut  entirely,  but  foreign  bodies,  or  hard,  spherical 
masses  of  faeces  frequently  become  lodged  in  the  strictured  portion  and 
cause  occlusion  with  rupture  of  the  intestine  and  fatal  peritonitis. 

Intestinal  indigestion,  flatulence,  and  loss  of  appetite  are  common 
in  this  condition,  and  occasionally  patients  are  seen  who  suffer  from 
skin  eruptions,  fever,  coated  tongue,  sallow  complexion,  jaundice,  and 
all  the  complications  of  auto-intoxication  due  to  the  accumulation  and 
decomposition  of  faecal  matter  above  a  stricture  of  the  rectum  or  sigmoid. 

The  straining  necessary  to  overcome  the  obstruction  is  often  so 
severe  that  inguinal  hernia  may  be  produced,  or,  as  in  a  case  seen  with 


STRICTURE   OP   THE  RECTUM  485 

Dr.  Ladinski  (Fig.  167),  it  may  result  in  prolapse  of  all  the  rectum 
below  the  stricture.  In  this  case  there  was  a  history  of  progressive  con- 
stipation but  no  evidence  whatever  of  syphilis  or  of  tuberculosis.  Ap- 
parently it  was  a  simple  inflammatory  process  which  had  resulted  in 
great  hypertrophy  of  the  rectal  walls  and  the  development  of  fibro- 
lipomatous tissue  surrounding  it.  Hulke  (Med.  Times  and  Gaz.,  Lon- 
don, 1879,  p.  504)  records  a  case  of  this  kind,  and  also  one  in  which 
complete  prolapse  of  the  uterus  was  brought  on  by  this  straining. 

With  the  diarrhoea  there  are  sometimes  discharged  large  quantities 
of  pus  tinged  with  blood,  and  occasionally  alarming  haemorrhages  occur. 
These  are  due  to  the  ulcerations  above  and  below  the  stricture.  The 
discharges  from  that  below  are  not  usually  mixed  with  fgeces,  being 
purulent  or  sanio-purulent,  and  quite  profuse;  those  from  the  ulcer 
above  the  stricture  are  mixed  with  fseces.  Thus  patients  will  describe 
being  called  to  stool  early  in  the  morning  and  passing  nothing  but  blood 
and  pus;  within  an  hour  or  two  they  attend  the  closet  again  and  have 
a  fffical  passage  with  some  pus,  and  later  in  the  day  various  calls  result 
in  passages  similar  to  that  of  the  morning. 

The  amount  and  character  of  the  discharges  from  a  stricture  will 
depend  largely  upon  its  cause.  In  syphilitic  stricture  the  discharge 
is  very  abundant,  always  sanious  and  dark-colored,  and  possesses  a  sort 
of  feculent  odor.  In  those  due  to  tubercular  or  simple  inflammation  the 
discharges  are  not  so  abundant,  they  are  not  frequently  mixed  with 
blood,  and  the  color  is  more  of  a  creamy  white  stained  with  faeces. 

Skin-tabs,  such  as  the  French  call  condyloma,  excoriations,  thinning 
of  the  perianal  skin,  and  sometimes  the  development  of  papillomata 
around  the  anus,  may  form  the  external  manifestations  of  stricture  of 
the  rectum.  Henry  Smith  states  that  the  skin-tabs  and  condylomata 
are  more  frequently  found  in  syphilitic  stricture  than  in  any  other 
variety,  and  that  he  had  often  made  a  diagnosis  of  this  condition  from 
the  external  appearances  alone,  and  found  his  opinion  corroborated  by 
a  more  thorough  examination. 

The  form  of  the  fgecal  passages  has  been  insisted  upon  as  an  impor- 
tant symptom  of  stricture  of  the  rectum.  As  such  it  has  been  greatly 
exaggerated.  It  is  a  perfectly  clear  mechanical  principle  that  the  faecal 
mass  must  assume  the  form  of  the  last  constriction  through  which  it 
passes;  therefore  it  must  take  the  shape  of  the  anal  aperture,  and  will 
not  represent  that  of  a  stricture  higher  up.  Grooved  or  tape-like  fsecal 
masses  are  often  fiill  of  import  to  the  inexperienced,  who  suppose 
that  they  are  always  due  to  stricture,  whereas  they  may  be  caused  by 
spasmodic  sphincters,  hypertrophied  skin-tabs,  or  hEemorrhoids.  The 
only  circumstances  under  which  tbe  faeces  retain  the  shape  of  the  stric- 
ture are  when  the  latter  is  at  the  anus  or  is  prolapsed  so  as  to  be  outside 


486  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

of  this  aperture.  Kelsey  was  fortunate  enough  to  see  a  case  in  which 
the  faecal  mass  retained  the  form  imparted  by  the  stricture,  owing  to 
the  fact  that  it  prolapsed  outside  of  the  anus  whenever  the  bowels 
moved.  In  Ladinski's  case  this  was  also  clearly  demonstrated,  because 
the  prolapse  was  constantly  down,  the  stricture  being  at  its  lower  end, 
and  therefore  the  fa?cal  mass  always  assumed  the  shape  of  the  stric- 
tured  caliber. 

When  the  stricture  is  very  low  down,  or  at  the  margin  of  the  anus, 
the  parts  assume  a  sort  of  inelastic,  tubular  condition,  the  sphincters 
lose  their  power  of  control,  and  the  patient  suffers  from  a  condition  of 
incontinence  and  constipation  at  the  same  time.  The  fluid  substances 
constantly  dribble  away,  whereas  the  formed  facal  matter  will  be  re- 
tained until  great  effort  or  solvent  enemas  result  in  its  removal. 

Dilatation  and  weakening  of  the  gut  wall  above  the  stricture  always 
occur,  and  cause  danger  of  perforation  or  rupture.  Tympanitic  reso- 
nance is  present  over  this  area  one  day  and  an  absolutely  flat  sound 
on  another,  owing  to  the  periodic  accumulation  of  faces  in,  and  empty- 
ing of  this  portion  of  the  intestine.  Perforation  of  this  thin  and  weak- 
ened wall  may  occur  without  absolute  obstruction,  owing  to  ulceration 
or  straining.  In  fact  it  most  frequently  occurs  in  this  way.  AMien  it 
is  preceded  by  obstruction  the  patient  suffers  from  nausea,  fsecal  vomit- 
ing, or  great  belching  of  feet  id  gases,  together  with  intense  pain  and 
swelling  of  the  abdomen,  rapid  pulse,  and  high  temperature.  After 
perforation  occurs  the  temperature  may  suddenly  drop  for  a  few  hours; 
if  the  patient  does  not  die  in  this  state  of  shock  it  will  rise  again,  and 
the  condition  will  develop  into  local  or  general  peritonitis.  "While  per- 
foration ordinarily  ends  fatally  this  is  not  invariably  the  case,  as  timely 
operation  may  save  the  patient's  life;  or  the  area  may  become  walled 
off  and  a  localized  abscess  formed,  which  of  course  terminates  in  a  faecal 
fistula. 

Diagnosis. — In  the  diagnosis  of  stricture  it  is  not  only  necessary  to 
determine  its  existence,  l)ut  also  its  seat,  its  pathological  character,  its 
extent,  and  the  degree  of  constriction.  When  within  4  inches  of  the 
anus  all  this  information  can  be  obtained  with  comparative  ease,  inas- 
much as  the  parts  can  be  reached  with  the  finger,  can  be  seen  through 
the  speculum,  and  sections  can  be  obtained  for  microscopic  examination. 
Above  this  limit  the  diagnosis  is  more  difficult. 

The  history  and  symptoms  of  the  case  will  give  valuable  information 
as  to  the  existence  and  probable  pathological  character  of  the  stricture. 
Previous  injury  or  operation,  diffuse  proctitis,  pelvic  cellulitis,  a  pro- 
longed labor,  the  history  of  perirectal  or  pelvi-reetal  abscess,  syphilis, 
fistula,  or  rectal  ulceration,  may  all  suggest  the  probable  existence  of 
stricture,  especially  if  associated  with  a  gradually  increasing  difficulty 


STRICTURE  OF  THE  RECTUM  487 

in  movement  of  the  bowels.  A  source  of  error  in  reading  such  symp- 
toms lies  in  the  fact  that  many  patients^,  after  having  suffered  from 
inflammatory  conditions  about  the  rectum  and  anus,  develop  the  habit 
of  irregularity  in  fgecal  movements.  They  learn  to  restrain  themselves 
on  account  of  the  pain  which  stools  occasion,  and  thus  become  accus- 
tomed to  visiting  the  toilet  only  once  in  two  or  three  days. 

Constipation,  such  as  would  indicate  stricture,  consists  in  the  re- 
quirement of  great  effort  to  secure  a  stool  even  though  the  desire  for 
defecation  is  urgent.  In  cases  of  infrequent  defecation  simply  due  to 
habit,  no  unusual  amount  of  straining  or  discomfort  is  required  to 
accomplish  the  act.  The  symptoms  may  lead  one  to  suspect  stricture, 
but  local  examination  alone  can  establish  the  diagnosis. 

Examination. — The  patient  should  be  placed  upon  his  side  in  the 
Sims^s  position  with  the  hips  flexed  upon  the  abdomen  and  elevated 
upon  pillows.  The  external  appearance  of  the  anus  is  frequently  quite 
suggestive. 

The  existence  of  fistulous  openings  around  the  margin,  especially 
if  they  are  multiple  and  preceded  by  progressive  constipation,  is  always 
suggestive  of  the  probability  of  stricture.  AAHiere  there  is  a  discharge 
from  the  parts,  the  character  and  odor  should  be  carefully  observed; 
these  have  been  described  in  connection  with  different  varieties  of 
ulceration,  but  the  odor  is  of  great  importance  in  differential  diagnosis, 
and  may  be  referred  to  again.  In  cancer  it  is  unique;  once  smelled 
it  is  never  forgotten;  it  is  neither  faecal  nor  feculent,  but  a  combination 
of  putrefaction,  gangrene,  decomposing  faeces,  and  rottenness  to  which 
no  other  bears  any  resemblance.  In  simple  inflammatory  or  tubercular 
strictures  the  discharges  may  be  comparatively  odorless.  In  syphilitic 
stricture  it  is  feculent,  but  if  ordinary  care  is  practised  in  the  manage- 
ment of  these  cases  the  odor  will  be  entirely  subdued.  In  carcinoma, 
however,  nothing  short  of  the  incinerating  box  of  a  crematory  will  de- 
stroy it.  Aside  from  the  odor,  the  discharges  from  carcinoma  and  syph- 
ilitic stricture  resemble  each  other  very  much;  they  are  both  compara- 
tively thin,  bloody,  and  purulent. 

In  simple  and  syphilitic  strictures  the  anus  is  ordinarily  not  much 
deformed;  the  fatty  cushions  around  it  remain  comparatively  intact. 
In  malignant  and  tubercular  strictures  it  is  ordinarily  sunken  in,  the 
fatty  cushions  around  it  are  absorbed,  and  it  presents  a  sort  of  infundi- 
buliform  appearance.  In  carcinoma  the  condition  of  the  anus  will  de- 
pend largely  upon  the  situation  of  the  growth  and  the  extent  to  which  it 
has  developed;  if  situated  high  up  and  it  has  not  gone  on  to  consti- 
tutional involvement,  emaciation,  and  cachexia,  the  anus  may  give  no 
indication  whatever  of  the  disease;  if  low  down,  however,  the  sphincter 
may  be  hypertrophied,  hard,  and  spasmodic,  and  the  seat  of  constant 


488  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

pain  in  the  early  stages,  but  later  the  spasm  gives  place  to  great  relaxa- 
tion, dribbling  of  the  discharges  occurs,  and  exuberant,  cauliflower-like 
growths  may  protrude  from  the  anus. 

The  chief  source  of  information  in  the  diagnosis  of  stricture  is 
examination  by  the  finger.  Great  gentleness  and  caution  should  be 
exercised  in  such  an  examination,  not  only  to  avoid  giving  the  patient 
pain  and  to  prevent  such  a  spasm  of  the  sphincter  as  would  interfere 
with  complete  examination,  but  because  it  is  altogether  possible  to  break 
down  the  soft  and  weakened  tissues  of  the  ulcerative  portion  and  cause 
rupture  with  dangerous  haemorrhage  or  perforation  of  the  peritonaeum. 
Even  with  the  utmost  gentleness  this  has  sometimes  happened  (Bull.  d6 
la  soc.  de  chir.,  Paris,  October  23,  1872). 

Upon  the  introduction  of  the  finger  into  the  anus  the  changes  in 
the  mucous  membrane  below  the  stricture  which  have  been  described 
may  be  observed.  If  the  finger  is  pushed  upward  it  may  enter  a  gradu- 
ally decreasing  cone-like  canal  which  leads  to  the  stricture,  or  it  may 
come  upon  a  sudden  decrease  in  the  caliber  of  the  gut  formed  either 
by  soft  granulations,  smooth,  hard,  cicatricial  tissue,  or  nodular,  in- 
durated, malignant  masses.  The  gradual  coarctation  .from  below  up- 
ward is  usually  associated  with  the  tubular  variety;  the  sudden  and  abrupt 
diminution  in  the  caliber  of  the  gut  is  due  to  an  annular  or  sickle-shaped 
stricture.  The  sensation  imparted  to  the  finger  by  the  touch  of  the 
stricture  is  very  important.  Many  clinicians  believe  that  they  can  posi- 
tively diagnose  malignancy  by  this,  and  certainly  no  one  will  deny  that 
a  surgeon  of  large  experience  can  by  this  means  alone  obtain  a  fair 
knowledge  of  the  condition.  If  hard  and  nodular  and  bulging  out  into 
the  rectum,  or  broken  down  in  its  center  and  forming  an  irregular, 
crater-like  ulcer  with  friable,  exuberant  granulations,  one  may  assume 
with  confidence  that  it  is  a  case  of  malignant  disease;  if,  on  the  other 
hand,  the  obstruction  is  comparatively  smooth,  hard,  and  contains  only 
a  few  minute  irregularities  beneath  the  mucous  membrane,  is  movable 
upon  the  sacrum  and  surrounding  tissues,  and  apparent!}^  confined  to 
the  walls  of  the  gut,  it  will  probably  belong  to  the  inflammatory  variety 
of  stricture.  In  malignant  stricture  the  diminution  in  the  size  of  the 
gut  is  usually  abrujjt,  whereas  in  the  syphilitic  type  it  is  gradual.  The 
latter  are  more  frequently  tubular  than  annular,  whereas  those  of  the 
simple  inflammatory  and  tubercular  type  are  ordinarily  annular  and 
involve  only  a  small  extent  of  the  rectum.  When  the  stricture  is 
reached,  one  should  never  yield  to  the  inclination  to  force  his  finger 
through  the  aperture,  especially  if  it  be  a  carcinomatous  or  ulcerative 
case.  1^0  good  whatever  can  come  from  such  a  procedure,  and  there 
is  always  danger  that  what  appears  to  be  the  caliber  of  the  gut  may 
possibly  be  the  entrance  into  an  ulcerative  diverticulum,  the  dividing 


STRICTURE  OF   THE  RECTUM 


489 


tissue  between  which  and  the  peritoneal  cavity  is  so  tliin  that  perfora- 
tion may  easily  result.  As  Malassez  has  pointed  out,  there  is  a  portion 
of  almost  every  stricture  which  is  composed  of  a  sort  of  proud  flesh,  soft 
and  easily  torn.    Any  undue  force  at  this  point  may  result  disastrously. 

The  thickness  and  height  to  which  a  stricture  extends  may  often 
be  determined  in  females  by  the  combined  vaginal  and  rectal  touch, 
which  should  never  be  omitted.  In  men  who  are  not  too  fleshy,  with  one 
hand  upon  the  abdomen  and  the  other  in  the  rectum  one  may  some- 
times grasp  a  tumor  or  a  long  stricture  between  them,  and  thus  deter- 
mine its  extent  upward.  Under  anaesthesia  it  is  possible  to  grasp  a 
tumor  of  the  sigmoid  between  two  fingers  introduced  into  the  rectum 
and  the  hand  upon  the  abdomen;  with  the  whole  hand  in  the  rectum 
this  can  always  be  done.  In  these  examinations  one  should  always  de- 
termine the  mobility  of  the  afl'ected  parts;  if  the  stricture  is  freely 
movable  upon  the  sacrum  and  other 
organs  of  the  pelvis,  it  will  be  much 
more  favorable  for  operative  inter- 
ference than  otherwise.  Wliere  it 
is  attached  to  the  sacrum,  the  pros- 
tate, the  uterus,  or  other  pelvic  or- 
gans, the  operation  will  be  difiicult 
and  the  prognosis  grave. 

When  the  symptoms  indicate 
the  existence  of  a  stricture  and  it 
can  not  be  made  out  by  digital  ex- 
amination, search  by  instruments 
vnll  often  succeed,  but  it  must  be 
remembered  that  instrumental  ex- 
ploration is  exceedingly  dangerous 
in  stricture.  A  rectal  bougie,  how- 
ever soft  and  flexible,  may  do  great 
damage  in  the  hands  of  the  inex- 
perienced. There  are  so  many 
sources  of  error  in  examination  by 
this  instrument  that  little  weight  is 
attached  to  it  as  a  diagnostic  means. 
It  may  be  caught  in  the  mucous 

folds  or  in  a  diverticulum  of  the  rectum  and  absolutely  fail  to  pass 
beyond  this  (Fig.  168);  at  the  promontory  of  the  sacrum  it  may  be 
arrested,  and,  owing  to  the  acute  flexure  of  the  sigmoid  upon  the  rec- 
tum, may  double  upon  itself,  coming  backward  into  the  rectal  ampulla 
instead  of  passing  into  the  sigmoid  flexure;  sometimes,  even  if  the  opera- 
tor is  skilful  enough  to  appreciate  when  it  is  thus  doubling  upon  itseli, 


Fig.  168. — Bougie  aekested  in  Diveeticu- 

lUlI    SUEEOUXDING    A    StEICTCEE. 


490 


THE  AXCS,  RECTUM,  .AND   PELVIC  COLON 


he  will  be  unable  to  introduce  it  any  farther.  A  bougie  which  is  stiff 
enough  not  to  double  upon  itself  is  also  stiff  enough  to  penetrate  a  dis- 
eased rectal  wall.  Soft  "Wales  bougies  ma}^  be  used  by  experienced 
hands  in  these  cases,  but  even  they  are  dangerous.  The  author  has 
several  times  had  these  instruments  introduced  into  the  rectum,  when 
operating  for  abdominal  conditions,  just  to  observe  the  amount  of  pres- 
sure exercised  by  them  upon  the  intestinal  wall,  and  from  these  experi- 
ments he  is  exceedingly  skeptical  in  regard  to  the  wisdom  of  ever  intro- 
ducing them  into  chronic,  inflamed  intestines  with  symptoms  of  stric- 
ture. Certainly  no  one  who  has  ever  seen  the  amount  of  pressure  that 
is  exercised  upon  the  gut  wall  by  one  of  these  instruments  will  take 
the  chances  of  attempting  to  force  one  through  a  strictured  intestine  in 
which  there  is  ulceration.  Aside  from  this  danger,  the  bougie  reveals 
nothing  definite  with  regard  to  stricture.  If  it  fails  to  pass,  one  can 
not  say  whether  the  obstruction  is  due  to  this  or  to  some  other  cause; 
if  it  passes,  one  can  not  say  there  is  no  stricture,  for,  as  Kelsey  says, 
"  a  bougie  of  good  size  will  often  pass  a  stricture  small  enough  to  pro- 
duce great  trouble  "  {op.  cit.,  p.  357). 

One  may  sometimes  use  it  to  advantage  through  the  proctoscope  by 
bringing  the  strictural  opening  into  sight  and  introducing  the  bougie 
through  it.     Otherwise  one  works  in  the  dark  when  they  are  used. 

The  reader  should  also  be  warned 
against  the  danger  of  introducing 
rectal  instruments  into  patients 
under  the  influence  of  angesthetics; 
the  only  guide  there  is  in  regard 
to  the  amount  of  traumatism  that 
is  being  produced  lies  in  the  sensa- 
tions of  the  patient,  and  one  may 
perforate  the  intestine  uncon- 
sciously if  this  safeguard  is  re- 
moved. The  pneumatic  procto- 
scope gives  much  more  informa- 
tion than  the  bougie  and  is  not 
nearly  so  dangerous;  through  it 
one  is  able  not  only  to  diagnose 
the  stricture  and  its  location,  but  often  its  caliber  and  pathological  na- 
ture as  well.  The  condition  of  the  parts  below  the  stricture  can  be  seen, 
and  if  the  obstruction  consists  in  neoplasms,  such  as  polyps  or  papillom- 
ata,  this  can  also  be  determined.  The  great  value  of  this  instrument 
is  enhanced  by  the  fact  that  there  is  practically  no  danger  in  its  use. 

It  is  introduced  through  the  internal  sphincter,  and  the  gut  is  in- 
flated so  that  one  can  see  clearly  ever}-  inch  of  the  way  before  advancing 


Fig. 


169. — Bodexuameb's    Bulbous    Kectal 
Bougie. 


STRICTURE  OF  THE  RECTUM  491 

the  instrument.  When  no  stricture  exists  in  the  rectum  itself,  a  few 
pressures  upon  the  hand-bulb  will  dilate  the  organ,  and  the  tube  can 
then  be  advanced,  its  end  always  being  clearly  in  view,  out  of  touch  with 
the  rectal  wall.  At  the  juncture  of  the  rectum  and  sigmoid  the  direc- 
tion of  the  gut  above  can  be  seen,  and  with  skilful  manipulation  the 
tube  can  be  carried  into  the  latter  just  as  safely  as  into  the  rectum. 
By  this  means  it  is  possible  to  bring  into  view  any  contracted  or  stric- 
tured  portion  of  the  gut  without  any  undue  pressure  or  danger  of  per- 
foration. After  this  has  been  done  and  the  end  of  the  tube  accurately 
adjusted  to  its  aperture,  the  external  cap  may  be  removed,  and  a  prop- 
erly adjusted  bulbous  bougie  (Fig.  169)  passed  through  the  stricture 
to  determine  its  caliber  and  extent.  These  instruments  and  their  uses 
have  been  already  described  (p.  139). 

Redometers. — Laugier  and  Tarnier  have  each  invented  instruments 
which  have  dilating  ends,  and  which  may  be  introduced  through  the 
stricture  and  then  dilated  and  allowed  to  collapse  gradually  until  they 
can  be  easily  withdrawn,  on  the  same  principle  as  an  Otis  urethrometer. 
The  author  having  had  no  experience  with  them,  is  unable  to  confirm 
or  deny  their  usefulness. 

In  the  absence  of  the  proctoscope,  or  where  for  any  reason  it  can 
not  be  applied,  one  may  have  resort  to  Simon's  method  of  introducing 
the  whole  hand  into  the  rectum  and  examine  the  parts  in  this  way.  It 
is  a  very  dangerous  procedure,  however,  where  there  is  chronic  inflam- 
mation of  the  organ. 

Laparotomy. — As  a  final  resort  in  the  diagnosis  of  stricture  one  may 
have  recourse  to  exploratory  laparotomy.  Formerly  such  a  radical 
measure  would  have  been  looked  upon  unfavorably;  to-day,  however, 
it  is  a  most  common  procedure,  and  comparatively  without  danger. 
Indeed,  it  is  less  dangerous  than  any  instrumental  examination  of  the 
rectum  in  diseased  conditions,  if  the  use  of  the  pneumatic  proctoscope 
be  excepted. 

In  making  such  an  examination  the  incision  should  always  be  made 
similar  to  that  employed  for  inguinal  colostomy  in  order  that  an  artifi- 
cial anus  may  be  made  at  the  time  if  it  is  found  necessary.  Moreover, 
this  incision  will  be  found  the  most  convenient  for  operations  upon  the 
sigmoid  flexure  and  upper  end  of  the  rectum.  After  the  incision  has 
been  made,  the  sigmoid  may  be  gently  dragged  out  of  the  opening  or 
run  through  the  fingers  until  the  strictured  area  or  neoplasm  is  felt  or 
found  absent. 

The  diagnosis  between  the  several  varieties  of  stricture  is  somewhat 
more  diificult;  but  the  most  important  distinction  to  be  made  is  that 
between  the  malignant  and  non-malignant.  In  a  general  way  one  may 
distinguish  them  as  follows: 


492  THE  ANUS,  RECTUM,   AND   PELVIC   COLOX 

Maligxant  Stricture  Xox-maligxaxt  Stricture 

Generally  occurs  in  persons  above  thirty-  Occurs  at  any  age,   ordinarily  between 

five  years  of  age.  twenty  and  fifty. 

Runs  its  course  ordinarily    in  two  or  The  patients  may  live  for  many  years 

three  years.    Constitutional  symptoms,  with  it.     General  health  remains  good 

such  as  loss  of  flesh  and  strength,  ap-  through  long  periods, 
pear  early  in  the  disease. 

Hereditary  influence  probable.  Xo  hereditary  connections. 

To  the  touch    hard,    nodular,    without  To   the  touch  it  is  smooth,   hard,   and 
pedicle  ;    protrudes    into   the   rectum  inelastic,  but  not  nodular, 
from  more  or  less  of  the  circumference  Rarely  attached  to  the  sacrum,  but  some- 
of  the  gut,  but  not  equably  ;   it  may  times  attached  to  organs  in  the  ante- 
occur  as  a  deep  excavating  ulcer  with  rior  portion  of  the  pelvis, 
sharp   edges   and   indurated   base,   or  The  discharge  may  be  abundant  or  lim- 
sometimes  as  a  fungous,  granulating,  ited,  thick  or  thin,  according  to  the 
cauliflower  growth.     May  be  movable,  nature  of  the  stricture, 
but  is  generally  attached  to  the  sacrum 
and  surrounding  parts. 

The  odor  is  nauseating,  gangrenous,  and  The  odor  is  faecal  or  feculent,  according 

unique.  to  the  amount  of  ulceration. 

A  distinct  cicatricial  or  fibrous  appear- 
ance upon  examination  through  the 
speculum. 

In  doubtful  conditions  microscopic  examination  of  an  excised  por- 
tion of  the  growth,  will  be  of  service,  but  one  should  not  rely  too 
implicitly  upon  it,  especially  if  the  result  of  the  examination  is  nega- 
tive. The  author  had  one  case  in  which  three  specimens  removed  from 
a  neoplasm  of  the  rectum  were  reported  as  non-malignant  by  three 
different  microscopists;  so  convinced  was  he  of  the  clinical  diagnosis 
which  had  been  confirmed  by  two  other  surgeons  that  he  advised  radical 
operation,  to  which  the  patient  consented.  After  the  tumor  was  re- 
moved more  thorough  examinations  of  its  deeper  portions  revealed 
clearly  its  carcinomatous  nature.  Hj-pertrophy  of  the  other  tissues, 
tubules,  and  glands  in  the  rectum  may  occur  as  a  result  of  irritation 
from  a  neoplasm,  and  the  sections  obtained  for  examination  (during  life) 
may  be  only  portions  of  these  hypertrophied  areas,  and  not  a  part  of  the 
malignant  disease  at  all.  Between  a  careful,  thorough  clinical  diag- 
nosis and  a  microscopic  examination  of  a  small  specimen  the  former 
seems  more  reliable,  though  the  value  of  the  latter  is  not  to  be  un- 
derrated. 

Between  the  varieties  of  inflammatory  stricture  differentiation  is 
much  more  difficult.  Eeference  has  been  made  to  the  microscopic  ap- 
pearances, the  changes  in  the  blood-vessels,  the  deposit  of  tubercles,  and 
the  development  of  fibrous  tissue  which  occur  in  the  three  difl'erent 
varieties,  but  unfortunately  such  examinations  can  only  be  made  after 
the  stricture  has  been  removed.     "Wliat  is  needed  is  some  method  to 


STRICTURE   OF   THE  RECTUM  493 

distinguish  the  different  varieties  in  the  early  examinations  in  order 
to  determine  positively  the  line  of  treatment  most  applicable  to  any 
given  case. 

Those  symptoms  upon  which  most  reliance  is  placed  are  the  follow- 
ing: Syphilitic  strictures  are  rarely  abrupt,  they  show  a  gradual  funnel- 
like contraction,  and  around  the  edges  of  the  ulcers  there  is  a  bluish- 
white  cicatrization. 

The  traumatic  or  simple  inflammatory  stricture  is  usually  abrupt 
and  may  be  limited  to  one  side  of  the  gut  as  a  falciform  contraction; 
it  is  generally  smooth,  covered  with  epithelium,  and  in  the  majority 
of  instances  is  near  the  anus.  Tubercular  stricture  may  occur  at  any 
portion  of  the  large  intestine;  it  is  always  associated  with  tubercular 
ulcers  and  caseating  tubercular  masses,  and  the  scrapings  from  such  an 
ulcer  will  generally  show  the  presence  of  tubercle  bacilli  and  giant-cells. 
The  appearance  of  the  ulcer  is  entirely  different  from  that  of  the  syphi- 
litic ulcer,  as  has  been  described  in  the  chapters  upon  these,  two  diseases. 
The  mucous  membrane  is  always  undermined  and  the  base  elevated, 
whereas  in  the  syphilitic  ulcer  the  edges  are  never  undermined  and  the 
base  is  always  crater-like  or  excavated. 

While  the  therapeutic  test  is  of  little  value  to  determine  the  nature 
of  the  stricture,  it  is  of  the  greatest  importance  in  that  it  checks  the 
extension  and  assists  in  healing  an  ulceration  if  it  be  specific.  Not  only 
this,  but  it  acts  as  a  real  alterative  and  tonic  in  cases  due  to  tuberculosis 
and  simple  inflammation. 

Microscopic  and  culture  tests  throw  light  upon  tubercular  strictures, 
but  the  finding  of  tubercle  bacilli  should  not  be  taken  as  an  absolute 
proof  of  the  tubercular  nature  of  a  stricture,  because  these  germs  may 
be  ingested,  carried  through  the  intestinal  tract,  and  thus  enter  the  dis- 
charges or  lodge  upon  the  ulcerations  without  being  the  cause  of  the 
same.  The  appearance  of  the  ulceration  below  the  stricture,  the  sensa- 
tion unparted  to  the  finger  in  digital  examination,  the  history  of  the 
case,  and  above  all  the  concomitant  symptoms,  such  as  pulmonary  tuber- 
culosis or  syphilitic  manifestations  elsewhere,  are  the  important  points 
in  differentiation. 

Treatment. — Eecognizing  the  fact  that  strictures  are  all  due  to  in- 
flammatory processes,  it  is  conceivable  that  proper  treatment  in  the 
early  stages  may  prevent  their  formation.  The  theory  upon  which 
gradual  dilatation  has  succeeded  in  curing  a  certain  number  of  acute 
strictures  of  the  urethra  is  that  it  squeezes  the  blood  out  of  the  stric- 
tured  area,  and  when  the  instrument  is  withdrawn  there  results  a  state 
of  arterial  hyperemia  which  results  in  absorption  of  the  newly  formed 
tissue.  During  the  early  stages  of  stricture  the  blood-vessels  remain 
intact,  and  are  not  materially  diminished  in  number;  the  plastic  deposit 


-i-94  THE  AXUS,  RECTUM,   AND   PELVIC  COLON 

is  soft  and  absorbable.  Similar  treatment  may  therefore  be  as  successful 
here  as  in  the  urethra.  If  the  inflammatory  process  is  syphilitic,  proper 
medication,  along  with  local  treatment,  will  control  it  and  check  the  cel- 
lular infiltration  which  results  in  stricture.  If  it  is  due  to  tuberculosis, 
the  administration  of  proper  remedies  and  forced  feeding,  together  with 
local  applications,  may  limit  the  extent  of  the  ulcer  as  well  as  the  fibrous 
deposit  around  it,  and  thus  control  to  a  certain  degree  the  extent  of 
the  stricture.  If  it  is  due  to  simple  infection,  careful  antiseptic  treat- 
ment may  often  prevent  the  formation  of  a  cicatrix  or  stricture.  When 
once  a  dense,  hard,  fibrous  stricture  has  formed,  the  blood-vessels  are 
no  longer  normal  in  their  caliber  or  number,  and  the  probability  of 
exciting  an  absorptive  hyperaemia  is  exceedingly  remote;  this  stage  once 
reached  there  is  no  method  that  offers  any  certain  hope  of  permanent 
cure. 

Dietary  and  Medicinal  Treatment. — The  patient  should  be  placed 
upon  a  nourishing  but  non-irritating  diet.  A  milk  diet  produces  a  hard, 
leathery,  insoluble  stool;  while  it  is  non-irritating  in  the  stomach  and 
upper  intestine  it  is  far  from  being  so  in  the  sigmoid  flexure  and  rec- 
tum, and  it  is  particularly  dangerous  in  stricture. 

As  a  rule  a  nitrogenous  is  preferable  to  a  carbohj'drate  diet,  but 
when  there  is  no  marked  colitis  this  need  not  be  insisted  upon.  A 
mixed  diet,  consisting  of  chopped  meats,  soups,  rice,  hominy,  ice-cream, 
fruits,  chocolate,  fish,  oysters,  etc.,  may  be  allowed;  with  these  a  liberal 
amount  of  cod-liver  oil  or  olive-oil  should  be  given.  Where  there  is 
marked  ulceration  rest  in  bed  is  always  advisable;  but  one  must  be  care- 
ful not  to  carry  this  too  far  and  develop  general  debility  by  long  con- 
finement and  lack  of  exercise. 

Where  diet  does  not  produce  a  regular  movement  of  the  bowels  it 
will  be  necessary  to  resort  to  some  laxative.  Strong  purgatives  are  to 
be  avoided,  inasnuich  as  they  not  only  produce  irritation  and  oedema, 
which  narrow  the  passage,  but  they  may  through  excessive  peristalsis 
and  tenesmus  cause  a  rupture  of  the  thin  gut  above  the  stricture.  For 
these  cases  there  is  nothing  better  than  small  doses  of  Epsom  salts  with 
bicarbonate  of  soda  in  the  proportion  of  three  to  one;  the  saline  mineral 
waters  are  also  useful,  but  patients  are  very  likely  to  develop  the  habit 
of  taking  them  in  too  large  quantities,  and  thus  induce  a  diarrhoea  rather 
than  a  normal  movement.  Castor-oil,  cascara  sagrada,  glycerin,  and 
licorice  powder  may  also  be  used  with  advantage.  It  is  advisable  in  the 
majority  of  cases  to  alternate  these  different  remedies.  The  resinous 
cathartics,  such  as  gamboge,  aloes,  podophyllin,  and  senna  should  be 
avoided.  Enemata,  if  properly  administered,  are  of  benefit,  but  the 
practice  of  introducing  them  through  long  tubes  is  not  only  dangerous 
but  useless.    If  the  tube  is  stiff  perforation  may  be  easily  produced;  if  it 


STRICTURE  OP  THE  RECTUM  495 

is  very  limber  it  will  pass  up  to  the  stricture,  double  upon  itself,  and 
thus  the  fluid  will  be  poured  out  into  the  rectal  cavity  just  as  it  would 
have  been  had  the  small  nozzle  of  a  syringe  been  used.  It  is  better  in 
these  cases  to  advise  the  patient  to  take  cold-water  enemata  from  a 
fountain  syringe  raised  about  2  feet  above  the  bed  or  floor  on  which 
he  lies.  He  should  be  in  the  knee-chest  posture  and  allow  the  fluid 
to  flow  in  slowly.  The  cold  water  will  temporarily  contract  the  blood- 
vessels, reduce  the  congestion,  and  thus  increase  the  caliber  of  the 
strictured  portion  for  the  time  being.  The  slight  elevation  of  the 
syringe  will  obviate  any  danger  from  pressure,  and  the  slow,  gentle 
current  will  not  excite  any  immediate  peristalsis.  As  much  as  2  or 
3  pints  of  cold  water  may  be  introduced  in  this  manner,  and  often 
with  the  happiest  results.  Occasionally  4  ounces  of  olive-oil  may  be 
injected  about  half  an  hour  before  the  enema  is  given.  This  lubricates 
the  parts,  and  sometimes  produces  a  smooth,  comfortable  movement 
of  the  bowels  without  the  enema.  G-lycerin,  turpentine,  and  salt  may  be 
added  to  the  cold  enema,  and  will  sometimes  be  of  material  assistance 
to  excite  peristaltic  action  and  proper  fsecal  movements. 

Diarrhoea  connected  with  a  stricture  of  the  rectum  is  generally  due 
to  one  of  two  causes,  viz.,  an  impaction  of  faeces  above  the  strictured 
point  or  an  acute  ulceration  of  the  intestine.  The  management  of  this 
condition,  therefore,  consists  in  the  removal  of  any  faecal  masses  which 
may  be  retained  above  the  stricture  and  treatment  of  the  ulceration. 
The  injections  of  oil,  solutions  of  ox-gall,  and  warm  water  may  result 
in  the  softening  and  removal  of  the  arrested  materials.  When  this 
has  been  accomplished  then  the  ulceration  can  be  treated,  as  has  been 
described  in  the  chapter  on  that  subject. 

Kelsey  states  that  acute  obstruction  sometimes  occurs  in  these  cases 
as  a  result  of  the  spasmodic  contraction  and  excessive  peristalsis,  and 
claims  {op.  cit.,  p.  362)  that  several  times  he  has  been  able  to  obtain 
a  movement,  in  apparent  obstruction  due  to  stricture,  by  the  adminis- 
tration of  large  doses  of  opium.  Although  with  no  experience  of  this 
kind,  the  author  would  certainly  hesitate  to  administer  very  large  doses 
of  this  drug  to  patients  who  are  suffering  from  symptoms  of  obstruc- 
tion unless  there  was  great  tenesmus,  griping,  and  pain.  Medicines,  as 
a  rule,  do  little  more  than  relieve  the  symptoms  in  the  majority  of  cases, 
and  yet  one  would  be  very  far  from  justified  in  omitting  their  use. 
Especially  is  this  true  with  regard  to  antisyphilitic  remedies.  Mercury 
and  the  iodides  have  a  positive  influence  in  promoting  the  resolution  of 
all  embryonic  fibrous  material,  as  Stille  pointed  out  many  years  since 
in  his  lecture  upon  plastic  adhesions  of  the  pleura.  Mercury  when  ad- 
ministered in  moderate  doses  has  been  shown  by  Keyes  to  have  a  positive 
tonic  influence,  to  increase  the  red  blood-corpuscles,  and  conduce  to 


496  THE  ANUS,   RECTUM,   AND  PELVIC  COLON 

the  patient's  general  health.     Therefore  these  drngs  may  act  in  a  bene- 
ficial way  in  non-specific  as  well  as  specific  strictures. 


LOCAL  AND  OPERATIVE  TREATMENT 

The  chief  local  and  operative  methods  used  in  the  treatment  of 
stricture  are: 

Dilatation  or  divulsion;  proctotomy;  excision;  entero-anastomosis; 
colostomy;  electrolysis. 

Theoretically  the  ulceration  should  always  be  healed  before  any 
surgical  treatment  is  begun  in  order  to  avoid  sepsis,  but  practically 
this  is  impossible,  for  in  many  instances  the  ulcers  can  not  be  cured 
so  long  as  the  stricture  exists.  Antiseptic  precautions  should  always 
be  taken  before  any  local  or  operative  treatment  of  the  stricture  is 
begun,  whether  it  be  dilatation,  proctotomy,  or  excision. 

Gradual  Dilatation.— This  method  is  that  most  generally  employed 
throughout  the  surgical  world,  notwithstanding  the  fact  that  it  is  not 
often  curative  and  entails  periodic  repetition  throughout  life.  It  is 
carried  out  by  the  aid  of  bougies  and  rectal  dilators  of  various  types;  it 
requires  a  considerable  amount  of  skill  and  judgment,  and  it  is  fraught 
with  danger  even  in  the  most  skilful  hands. 

Bougies. — There  has  been  devised  a  large  variety  of  rectal  bougies, 
some  of  them  useful  and  many  of  them  positively  detrimental.  Those 
of  Wales,  Crede,  Andrews,  and  Hegar  (Figs.  81  and  170)  comprise  the 

most  useful  ones  for  the  treat- 
ment of  rectal  stricture.  The 
old  conical  rectal  bougie  made 
Fig.  no.-CREDE's  Rectal  Bougie.  0^  woven  linen  or  silk  and  Cov- 

ered with  shellac,  is  a  most 
dangerous  instrument  and  no  longer  used  by  rectal  surgeons.  The 
methods  of  introducing  the  bougies,  however,  are  of  more  importance 
than  the  instruments  themselves.  The  dangers  of  traumatism  and  per- 
foration of  the  rectal  wall  from  the  use  of  stiff  instruments  have  already 
been  described. 

The  Wales  instruments  were  devised  to  obviate  this  danger,  and 
they  are  superior  to  other  instruments  in  this  respect. 

Methods  of  Introduction. — The  patient  is  laid  upon  the  side  in  the 
Sims's  posture  with  the  thighs  flexed  upon  the  abdomen.  Tlie  bougie 
is  then  gently  introduced,  if  practicable  using  the  left  index  finger  to 
guide  its  tip  into  the  orifice  of  the  stricture.  In  the  majority  of  cases 
this  is  impracticable,  as  the  sphincter  will  not  admit  the  passage  of 
the  finger  and  the  bougie  at  the  same  time  without  great  pain.  When 
the  bougie  is  arrested,  a  current  of  water  is  injected  through  it  in 


.STRICTURE   OF   THE  RECTUM  497 

order  to  lift  out  of  its  way  any  folds  of  mucous  membrane  or  other 
obstruction. 

If  the  stricture  is  at  the  margin  of  the  anus  or  within  an  inch  of 
the  same,  it  is  an  easy  matter  to  introduce  the  instrument,  but  if  it  is 
higher  up  it  is  always  a  matter  of  chance  whether  it  enters  the  stric- 
tured  canal  or  not.  In  stricture  above  the  levator  ani  there  is  generally 
a  sagging  or  procidentia  of  the  constricted  portion  of  the  gut  into  that 
below,  thus  forming  a  sort  of  cul-de-sac  around  it.  The  end  of  the 
bougie  is  very  likely  to  be  arrested  in  this  instead  of  entering  the  stric- 
tured  aperture  (Fig.  168).  Especially  is  this  the  case  in  malignant 
and  annular  strictures,  where  the  orifice  may  be  in  the  center  or  at  any 
other  portion  of  the  circumference.  In  syphilitic  strictures,  in  which 
the  approach  to  the  orifice  is  funnel-shaped  and  gradual,  this  accident  is 
not  so  likely  to  occur.  At  any  rate,  it  is  always  a  matter  of  uncertainty 
when  the  bougie  is  arrested  whether  its  tip  is  engaged  in  the  stricture, 
in  this  sulcus,  or  in  a  mucous  fold,  and  in  diseased  conditions  any  exer- 
cise of  force  at  such  points,  even  with  these  soft  instruments,  may  result 
disastrously. 

The  Author's  Method  of  introducing  Bougies  into  St7-ictures. — In 
order  to  obviate  these  dangers  and  be  more  accurate  in  the  use  of 
the  instruments,  the  author  has  for  several  years  been  in  the  habit  of 
introducing  a  proctoscope  up  to  the  point  of  the  stricture  and  locating 
its  end  over  the  aperture;  the  bougie  is  then  gently  introduced  through 
it  into  the  stricture.  By  this  means  it  is  known  that  the  bougie  is  in 
the  right  track;  the  proper  size  can  be  easily  selected,  and  it  may  be 
gently  pushed  upward  with  or  without  the  use  of  a  stream  of  water  and 
without  any  doubt  of  its  being  in  the  right  track.  The  bougie  which  is 
used  for  this  purpose  is  a  Wales  instrument  with  no  flange  upon  its  end, 
so  that  the  speculum  can  be  removed  as  soon  as  the  former  is  engaged 
in  the  stricture.  It  is  best  to  introduce  a  small  instrument  first,  pass 
it  through  the  stricture,  and  then  introduce  one  size  after  another 
until  the  largest  one  which  can  be  passed  without  actual  pain  has  been 
reached.  When  this  has  been  done,  the  speculum  is  withdrawn  and  the 
bougie  allowed  to  remain  in  position  for  five  to  fifteen  minutes.  By 
this  means  not  only  is  the  bougie  accurately  introduced  into  the  orifice 
of  the  stricture,  but  it  is  possible  to  see  the  condition  of  affairs  at  each 
introduction,  and  also  to  realize  how  much  of  the  friction  and  grasping 
of  the  bougie  is  due  to  the  stricture  itself  as  distinguished  from  that 
of  the  external  sphincter  muscle.  The  method  is  simple,  accurate,  prac- 
tical, and  far  superior  to  the  old  uncertain  methods. 

The  application  of  remedies  to  the  stricture  at  the  time  of  dilata- 
tion was  first  employed  by  Dessault,  who  introduced  a  tampon  in- 
corporated with  mercury  through  the  constriction  and  left  it  there. 
32 


498  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

This  method  is  of  no  practical  value,  but  in  cases  where  there  is  ulcera- 
tion, the  bougie  may  be  lubricated  with  such  ointments  as  may  be 
thought  beneficial  to  the  condition.  The  author  has  sometimes  used  an 
iodoform  ointment  in  the  strength  of  1  dram  to  the  ounce,  and  some- 
times a  mercuric  ointment;  but  of  recent  years  he  finds  it  more  satis- 
factory to  use  a  simple  lubricant  upon  the  instruments,  and  depend  upon 
more  accurate  methods  in  the  application  of  drugs  to  the  ulcerated 
areas. 

The  frequency  with  which  the  bougie  should  be  introduced  depends 
upon  the  amount  of  reaction  occasioned.  At  first  it  may  be  advisable 
to  introduce  it  every  day,  provided  the  patient's  anus  and  rectum  do 
not  become  inflamed  and  tender  from  the  proceeding.  Often  it  will  be 
found  necessary  to  allow  several  days  to  intervene  between  seances. 
Any  haste  in  this  regard  may  result  in  the  development  of  acute  inflam- 
matory conditions  which  will  not  only  retard  the  final  result,  but  increase 
the  stenosis  and  add  a  real  danger  to  the  condition.  It  may  be  set  down 
as  a  rule,  therefore,  that  wherever  the  bougie  produces  any  tenderness 
or  considerable  pain  it  should  not  be  introduced  again  until  all  this  has 
passed  away.  Too  rapid  increase  in  the  size  of  the  instruments  may 
also  produce  this  effect.  One  should  never  introduce  more  than  three 
bougies  at  one  sitting;  he  should  keep  a  record  of  the  sizes  used,  and 
always  begin  with  one  number  lower  than  the  largest  used  at  the  previous 
treatment;  if  this  passes  easily  and  without  pain,  he  may  then  introduce 
the  highest  number  used  on  the  previous  day,  and  if  it  passes  freel}'', 
introduce  one  size  larger.  Before  removing  the  instrument  a  warm 
solution  of  boric  acid  is  injected  through  it,  and  thus  everything  above 
the  stricture  is  cleansed  as  far  as  possible. 

The  patient  should  be  kept  quiet  for  half  an  hour  after  the  treatment, 
and  if  any  bleeding  follows  the  withdrawal  of  the  instrument  he  should 
not  be  allowed  to  leave  the  office  until  his  rectum  has  been  examined, 
to  ascertain  if  any  considerable  haemorrhage  is  taking  place,  and  if  neces- 
sary control  it. 

Betention  of  Bougies. — The  length  of  time  a  bougie  should  remain 
in  the  stricture  after  it  has  once  been  introduced  is  a  somejvhat  mooted 
question.  Kelsey  {op.  cit.,  p.  353)  claims  that  it  is  advantageous  to 
allow  the  instrument  to  remain  in  the  stricture  several  hours,  or  even 
through  the  night.  Crede  (Archiv  fiir  klin.  Chir.,  1892,  S.  175)  says 
that  the  bougie  should  be  left  in  position  as  long  as  it  is  grasped  by  the 
sphincteric  contraction  of  the  circular  fibers,  and  that  having  been  once 
introduced  it  should  be  retained  until  it  comes  away  without  any  fric- 
tion or  eifort  upon  the  part  of  the  surgeon.  Keyes,  however,  believes 
in  rapidly  increasing  the  size  of  the  dilating  instrument,  and  in  intro- 
ducing a  bougie  with  considerable  force  in  order  to  accomplish  this. 


STRICTURE  OF   THE  RECTUM 


499 


Ball  {op.  cit.,  p.  173)  maintains  that  the  length  of  time  which  the  bougie 
should  remain  depends  largely  upon  the  character  of  the  stricture.  In 
dense,  hard,  cicatricial  strictures  he  believes  in  allowing  the  instrument 
to  remain  in  situ  for  several  hours;  while  in  soft,  flexible  ones  he  ad- 
vises not  only  the  vise  of  comparatively  small  instruments,  but  their 
immediate  removal  after  having  passed  through  the  strictured  area. 
MacMaster  (N.  Y.  Med.  Jour.,  1876,  p.  376)  and  Quenu  and  Hartmann 
{op.  cit.,  p.  311)  are  advocates  of  the  immediate  removal  of  the  bougie 
after  it  has  once  passed  the  stricture.  The  rule  is  as  we  have  stated 
above,  but  occasionally,  where  the  stricture  is  very  tight,  having  once 
succeeded  in  introducing  the  bougie,  it  may  be  allowed  to  remain  for 
considerable  periods  of  time,  even  for  twenty-four  hours,  in  order  that 
its  pressure  may  gradually  soften  the  stricture,  and  by  pressure  upon 
the  parts  reduce  the  congestion  and  oedema  which  narrow  the  orifice. 
In  strictures  of  moderately  large  caliber  there  is  no  advantage  in  main- 
taining the  bougie  in  position  longer  than  is  necessary  to  overcome  what- 
ever spasm  it  excites. 

Aside  from  bougies,  numerous  ingenious  instruments  have  been  de- 
vised for  the  dilatation  of  stricture.  Among  them  are  sponge,  tupelo,  and 
laminaria  tents  that  have  metallic  tubes  running 
through  their  centers  in  order  to  facilitate  the  es- 
cape of  gas.  These  are  introduced  through  the  stric- 
ture and  held  in  position  by  tampons  until  the  mois- 
ture of  the  bowel  causes  them  to  swell  and  gradually 
dilate  the  stricture.  They  are  dangerous  instruments, 
however,  inasmuch  as  there  is  no  means  of  gauging 
the  amount  of  pressure  which  they  exert  upon  the 
weakened  and  sometimes  friable  intestinal  walls.  The 
points  at  which  stricture  is  generally  located  are  very 
slightly  sensitive  to  pain,  and  laceration  or  even  rup- 
ture of  the  gut  may  result  without  the  patient  being 
aware  that  the  injury  has  taken  place.  Such  instru- 
ments are  therefore  inadvisable. 

Others,  such  as  hollow  dilating  bougies  made  of 
soft  rubber  and  arranged  so  as  to  be  dilated  by  the 
injection  of  water  or  air  after  they  are  passed  through 
the  stricture,  have  been  advised  by  various  surgeons. 
Ball  says  that  the  ordinary  Barnes's  dilators  are  supe- 
rior to  any  of  these  devices;  he  has  used  them  a  num- 
ber of  times  for  the  dilatation  of  stricture,  and  with 
excellent  results;  they  are  of  hour-glass  shape,  and,  after  they  have  been 
once  introduced  and  distended,  they  will  remain  in  situ  as  long  as  is 
necessary.    Where  the  stricture  is  within  the  lower  3  inches  of  the  gut. 


Fig.  in.— Sims's 
Rectal  Dilatob. 


500 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


the  author  is  in  tlie  habit  of  using  the  simple,  okl-fashioned  C'nscos's 
speeuhim  for  dilatation.  It  is  easy  of  introduction  and  very  effectual 
for  this  purpose. 

Eectal  dilators  of  various  patterns  have  been  devised  for  the  treatment 
of  stricture,  the  best  known  of  which  are  Sims's  (Fig.  171),  Mathews's, 
Nekton's,  and  Durham's  (Fig.  172),     Recently  Martin,  of  Cleveland, 

has  introduced  one  which  he  calls  a 
"  coactor."  There  is  no  doubt  that  in 
experienced  hands  these  instruments 
sometimes  prove  superior  to  the  use 
of  the  bougie  to  obtain  rapid  results. 
The  friction  and  pressure  necessary 
to  dilate  a  stricture  by  the  use  of  bou- 
gies may  result  in  dragging  and  tear- 
ing of  the  tissues,  whereas  the  rectal 
dilators  may  be  introduced  through 
the  stricture  and  gradually  widened, 
thus  avoiding  any  friction.  The  dan- 
ger of  these  instruments  is  in  our 
inability  to  estimate  how  much  pres- 
sure is  being  exerted  upon  the  rectal 
wall;  there  is  no  means  to  determine 
when  laceration  or  rupture  is  about 
to  occur,  and  after  it  has  once  taken 
place  the  damages  can  rarely  be  re- 
paired. Such  instruments  should 
never  be  used  except  in  the  hands 
of  operators  familiar  with  the  amount 
of  pressure  which  they  exert,  and  hav- 
ing a  knowledge  of  the  friability  of 
the  different  classes  of  stricture.  On 
the  whole  one  must  conclude  that  the 
bougie  properly  used  is  the  safest  and 
most  satisfactory  instrument  for  grad- 
ual dilatation. 

Rapid  Dilatation  or  Divulsion. — 
This  method,  so  popular  at  one  time 
in  strictures  of  both  the  rectum  and  urethra,  has  practically  and  justly 
become  obsolete.  Mathews  still  employs  it  in  constrictions  following 
operative  interference  at  the  anus  or  very  low  in  the  rectum.  At  this 
point  the  method  may  be  employed,  and  no  doubt  one  will  obtain  some 
very  rapid  and  excellent  results,  especially  if  bougies  are  passed  regularly 
thereafter  to  maintain  the  dilatation. 


Fig.  172. — Dlkham"s  Rectal  Dilator. 


STRICTURE   OF   THE  RECTUM  501 

The  operation  consists  in  a  raj)id  distention  of  a  fibrous  or  cicatricial 
tube  which  is  often  friable  and  easily  torn.  When  such  distention  takes 
place,  a  rupture  either  complete  or  partial  is  the  inevitable  result,  and 
it  is  impossible  to  tell  in  which  direction,  where,  and  to  what  extent 
this  will  occur.  Naturally  the  anterior  and  lateral  portions  of  the  rec- 
tum being  the  thinnest  and  least  protected  will  ordinarily  be  the  site 
of  the  injury,  and  this  being  in  the  neighborhood  of  the  peritoneal  cavity 
adds  a  double  hazard  to  the  operation;  haemorrhage,  peritonitis,  infec- 
tion, and  abscess  are  the  natural  sequences  of  such  an  accident.  They 
have  all  been  observed  by  Trelat  (Jour,  de  la  soc.  de  chir.,  Paris,  1872, 
p.  573)  (ibid.,  p.  450,  and  Jour,  de  la  soc.  anat.,  1873,  p.  400)  and  death 
has  not  infrequently  resulted  either  from  immediate  shock  or  sub- 
sequent complications.  The  stretching  of  the  stricture  is  done  either 
with  the  fingers  or  with  specially  devised  instruments,  such  as  the 
dilators  mentioned  above. 

The  operation  has  nothing  whatever  to  recommend  it,  save  that  it 
produces  an  immediate  increase  in  the  caliber  of  the  stricture,  but  it 
does  so  at  such  risks  that  the  end  can  not  justify  the  means.  Moreover, 
these  ends  may  be  accomplished  by  simpler  and  less  dangerous  methods. 

Electrolysis,  Cauterization,  and  Raclage. — For  a  number  of  years 
there  have  been  frequent  reports  of  strictures  of  the  rectum  treated  by 
electrolysis.  Le  Fort  (Gaz.  des  hopitaux,  Paris,  1873,  p.  231)  has  re- 
corded a  number  of  cases,  originating  a  method  by  which  he  claims  to 
have  obtained  radical  cures.  His  method  consists  in  the  introduction 
of  an  electrode  shaped  like  a  rectal  bougie.  It  is  insulated  except  near 
its  end,  where  there  is  a  metallic  contact  through  which  the  electric 
current  passes.  The  instrument  is  introduced  until  this  metallic  area 
is  brought  within  the  grasp  of  the  sphincter,  and  then  with  the  nega- 
tive pole  attached  to  it  and  the  positive  pole  held  in  the  patient's  palm, 
or  attached  to  some  other  portion  of  his  body,  a  mild  galvanic  current 
is  turned  on  and  allowed  to  flow  for  considerable  periods  of  time.  In 
some  cases  the  instrument  is  allowed  to  remain  in  overnight,  and  the  au- 
thor claims  to  have  obtained  most  satisfactory  results.  Xewman  (Jour. 
Amer.  Med.  x4.ss'n,  1891,  p.  701)  describes  another  method  of  applying 
this  principle;  he  claims  to  have  first  used  it  in  1871.  It  was  also  used 
by  Beard  in  1874  (Archives  of  Electricity  and  ISTeurology,  vol.  i,  p.  98), 
who  described  the  process  of  decomposing  a  compound  body  by  elec- 
tricity, and  claimed  to  obtain  a  "  galvanic  chemical  absorption  "  of  the 
stricture.  Xewman's  electrode  consists  in  a  metallic  tip  fastened  to  an 
insulated  stem.  The  shape  of  the  tip  may  be  cylindrical  or  olive,  from 
I  of  an  inch  to  1^  inch  in  length,  and  from  1-|  to  3  inches  in  cir- 
cumference. 

The  patient  is  placed  in  the  Sims's  position;  the  positive  pole  is 


502  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

grasped  in  the  palm  of  the  hand  or  placed  upon  the  abdomen;  the  rectal 
electrode  is  then  introduced  up  to  the  stricture  and  engaged  in  its  orifice, 
and  the  current  of  froin  5  to  20  milliamperes  is  turned  on.  With  ordi- 
nary pressure  he  claimed  that  within  five  to  fifteen  minutes  the  bougie 
will  gradvially  pass  through  the  stricture  without  any  rupture  or  abrasion 
of  its  surface.  He  reported  12  cases  in  which  dilatation  and  other  meth- 
ods had  been  tried  without  avail,  and  claimed  to  have  cured  9,  the  other 
3  having  been  improved.  In  1  case  in  which  the  method  was  used,  he 
states  that  he  had  the  opportunity  of  making  a  post-mortem  examination 
some  years  afterward  and  found  no  evidence  whatever  of  stricture;  he 
advises  the  application  of  the  current  about  once  in  two  weeks.  The 
claims  for  this  method  have  been  frankly  stated,  but  having  tried  it  in 
urethral  strictures  and  found  no  benefit  therefrom,  the  author  sees  no 
reason  to  believe  that  it  will  cure  those  of  the  rectum. 

Proctotomy. — This  operation  is  the  one  generally  recommended  in 
rectal  stricture.  It  consists  in  partial  or  complete  section  of  the  stric- 
ture. It  is  described  in  the  text-books  as  internal  and  external  proc- 
totomy. The  term  external,  however,  is  misleading,  inasmuch  as  the 
incision  is  not  made  from  the  outside,  but  simply  extends  from  the  upper 
limits  of  the  stricture  downward  through  the  rectum,  anus,  and  post- 
anal structures.  It  is  better  to  describe  the  two  operations  as  partial 
proctotomy  and  complete  proctotomy. 

Internal  or  Partial  Proctotomy. — This  operation  consists  in  cutting 
or  nicking  the  stricture  with  the  view  of  facilitating  dilatation  by  bou- 
gies or  other  instruments.  The  first  mention  of  this  operation  is  that 
by  Stafford  (London  Med.  Gaz.,  1834,  p.  607).  The  operation  is  com- 
parable to  that  of  internal  urethrotomy,  and  is  performed  b}'^  incising 
the  stricture  with  a  blunt-pointed  bistoury,  or  with  some  specially  de- 
vised instrument  similar  to  the  urethrotome  of  Civiale  or  Otis. 

The  stricture  may  be  cut  deeply  in  the  posterior  region,  or  it  may 
be  simply  nicked  at  different  points  around  its  circumference.  The 
operation  is  a  very  dangerous  one,  especially  when  the  stricture  is  situ- 
ated at  some  distance  from  the  anus.  Haemorrhage  is  a  possibility,  al- 
though there  has  been  no  fatal  occurrence  from  this  accident;  the  danger 
lies  in  infection,  sepsis,  and  diffuse  periproctitis.  It  is  unnecessary  to 
enlarge  upon  the  possibilities  and  probabilities  of  infection  from  an  im- 
perfectly drained  wound  well  up  within  the  rectum  where  there  are 
always  numerous  bacteria  present;  the  accidents  which  have  followed 
this  operation  and  the  false  principle  upon  which  it  is  based  have  ren- 
dered the  procedure  practically  obsolete.  There  are  occasional  cases  of 
valvular  or  falciform  strictures  situated  at  a  distance  from  the  anus  in 
which  it  may  be  Justified,  especially  if  done  with  some  of  the  modern 
appliances,  such  as  the  Pennington  clip  or  hysterectomy  forceps.     In 


STRICTURE  OF  THE  RECTUM  503 

such  cases  the  clip  or  forceps  is  applied  over  the  valve-like  stricture  and 
made  to  grasp  as  much  of  the  tissue  as  possible;  it  remains  on  until 
it  cuts  its  way  through,  thus  widening  the  caliber  of  the  gut.  It  re- 
quires from  five  to  six  days  for  this  to  be  accomplished,  but  there  is 
little  danger  of  hemorrhage  or  sepsis  by  either  of  these  methods. 

Wliere  the  stricture  is  tubular,  or  involves  any  extent  in  the  length 
of  the  gut,  these  procedures  will,  of  course,  be  impracticable.  Internal 
proctotomy  by  simple  incision  is  no  longer  countenanced  by  operative 
surgeons,  for  the  slight  benefits  derived  from  it  are  out  of  all  proportion 
to  the  dangers  incurred;  therefore  it  need  not  be  discussed  further. 

Complete  Proctotomy. — This  operation,  called  also  linear  posterior 
and  external  proctotomy,  consists  in  an  incision  in  the  posterior  median 
line  of  the  rectum  extending  from  the  upper  limits  of  the  stricture  down 
through  the  anus  and  tissues  posterior  to  it.  The  operation  was  technic- 
ally first  devised  by  Humphreys  (Ass'n  Med.  Jour.,  London,  1856,  p. 
21),  although,  as  Quenu  and  Hartmann  say,  it  had  been  done  practically 
many  years  before  in  operations  upon  fistulas  associated  with  stricture. 
To  Humphreys,  however,  belongs  the  credit  of  establishing  the  operation 
as  a  procedure  of  choice. 

In  the  early  operations  by  this  method  the  chain  ecraseur  or  the 
actual  cautery  was  used  to  incise  the  parts.  Both  of  these  methods  were 
useful  in  that  they  avoided  haemorrhage;  but  the  fact  that  they  are  both 
followed  with  denser  cicatrization  than  simple  incision,  and  that  the 
methods  of  controlling  haemorrhage  are  so  complete  that  it  no  longer 
gives  any  great  anxiety,  have  rendered  the  use  of  these  instruments  un- 
necessary. The  operation  is  performed  by  introducing  a  blunt-pointed 
bistoury  through  the  stricture  and  cutting  downward  and  backward  in 
the  median  line  through  all  the  walls  of  the  intestine,  through  the  in- 
ternal and  external  sphincter  out  into  the  skin.  It  is  most  important 
that  the  incision  through  the  sphincters  and  skin  should  extend  back- 
ward to  the  tip  of  the  cocc3rx  in  order  that  there  shall  be  no  possible 
point  for  lodgment  of  faecal  matters  and  purulent  discharges.  The  dan- 
gers of  incontinence  from  this  operation  have  been  greatly  exaggerated. 
It  will  be  remembered  that  onlv  a  few  of  the  fibers  of  the  external 
sphincter  around  the  very  margin  of  the  anus  are  circular,  and  that 
those  which  extend  backward  and  are  attached  to  the  coccyx  do  not 
decussate;  therefore,  an  incision  in  this  line  will  not  sever  many  of  the 
muscular  fibers,  but  simply  separate  them  and  not  destroy  their  contrac- 
tile power.  Occasionally  where  a  large  cicatrix  is  formed,  separating  the 
ends  of  the  internal  sphincter,  a  certain  amount  of  incontinence  may 
result,  but  this  is  rare.  At  any  rate,  the  incontinence  which  follows  this 
operation  is  not  comparable  to  the  discomforts  and  dangers  of  a  stricture, 
and  therefore  the  patient  must  submit  to  the  lesser  evil.     On  account 


504  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

of  the  time  required  for  the  parts  to  heal,  AVeir  suggested  that  the  in- 
cision be  made  through  the  stricture  and  down  into  the  hollow  of  the 
sacrmn,  from  which  point  a  drainage-tube  is  carried  out  through  the 
skin  and  the  post-anal  tissues  without  incising  the  sphincters.  Kelsey 
states  that  he  has  tried  this  in  several  cases,  with  the  result  of  saving 
much  time.  "  The  tube  should  be  left  in  until  all  danger  of  periproctitis 
has  passed.  If  there  is  no  rise  of  temperature  by  the  fourth  day,  it  may 
be  safely  removed,  and  the  wound  caused  by  it  will  generally  heal 
promptly."  It  seems  improbable  that  this  operation  would  end  other- 
wise than  in  a  fistula,  which  would  eventually  have  to  be  cut — the  very 
proceeding  which  it  is  intended  to  obviate. 

Another  method  of  hastening  the  healing  of  the  lower  end  of  the 
wound  consists  in  freshening  the  surfaces  and  drawing  the  edges  to- 
gether by  deep  sutures  after  granulation  has  once  begun.  Both  of  these 
methods  are  based  upon  theory.  The  fact  is,  the  external  wound  nearly 
always  heals  before  the  internal,  and  it  is  difficult  to  keep  it  sufficiently 
open  to  secure  proper  drainage.  Moreover,  as  the  after-treatment  con- 
sists in  persistent,  thorough  dilatation,  it  is  perfectly  plain  that  any 
attempt  to  suture  the  anal  wound  together  would  not  only  be  useless 
but  cruel  to  the  patient.  Xo  effort  should  be  made  to  narrow  the  external 
outlet  until  the  stricture  has  been  obliterated,  and  until  the  wound  or 
ulceration  about  it  has  completely  healed.  The  dangers  in  this  operation 
as  in  internal  proctotomy,  are  sepsis,  periproctitis,  and  haemorrhage.  As 
said  before,  the  haemorrhage  can  be  easily  controlled  by  packing  with 
gauze  or  charpie;  the  sepsis  and  periproctitis  must  be  avoided  by  thor- 
ough antisepsis  before  the  operation  and  complete  drainage  afterward. 
It  is  well,  after  having  incised  the  stricture  and  packed  the  wound,  to 
carry  a  large-sized  drainage-tube  into  the  gut  above  and  fasten  it  in 
this  position  so  that  gas  and  fluid  faecal  matter  will  not  accumulate  and 
force  the  packing  out  of  position. 

The  after-treatment  of  complete  posterior  proctotomy  consists  in 
thorough  antiseptic  irrigation,  followed  by  dilatation  and  loose  packing 
of  the  wound  with  iodoform  or  sterilized  gauze.  In  these  cases,  as  has 
been  said  in  fistula,  great  harm  can  be  done  by  packing  the  wound  too 
tightly;  simply  introduce  enough  gauze  into  the  incision  to  protect  it 
from  fffical  matter  and  to  absorb  its  discharges.  Of  course  this  does  not 
apply  to  the  original  packing  for  the  control  of  hgemorrhage,  which 
should  be  introduced  very  firmly  into  the  wound.  The  operation  is  not 
applicable  or  advisable  in  cases  of  malignant  stricture,  although  some 
authorities  believe  that  the  patient's  condition  may  be  benefited  by  in- 
cising a  stricture  even  of  this  character. 

The  possibility  of  there  being  two  or  more  strictures,  one  above  the 
other  (Fig.  173),  should  always  be  remembered,  and  the  operation  should 


STRICTUKE   OF   THE   RECTUM 


505 


not  be  concluded  until  one  is  able  to  introduce  a  full-sized  bougie  Trell 
into  the  sigmoid  flezure. 

This  operation,  considered  so  simple  and  without  danger,  is  said  by 
most  authorities  to  give  excellent  results.  In  the  author's  experience 
the  results  have  not  been  uniform  or  satisfactor}^;  notwithstanding  com- 
plete incision,  there  has  been  no  marked  case  of  incontinence,  but  re- 
currence of  the  stricture  has  been 
the  invariable  rule.  This  observa- 
tion is  in  keeping  with  those  of  the 
statistics  taken  from  the  thesis  of 
Laehowski  (Paris,  189i-'95).  In 
32  observations  the  results  were  as 
follows:  Three  immediate  deaths 
from  erysipelas;  4  deaths  within 
four  years  from  cachexia  or  phthi- 
sis; 21  recurrences,  9  of  which  oc- 
curred during  the  first  year  and  4 
during  the  second  year;  and  3  in- 
valids were  lost  sight  of.  Only  1 
case  out  of  the  32  is  noted  as  abso- 
lutely cured  (Verneuil).  Protracted 
ulceration  and  recurrence  of  the 
strictures,  together  with  more  or 
less  incontinence  of  fseces,  were 
the  results  in  a  large  majority  of 
cases. 

Bullard  {op.  cit.)  states  that  he 
has  rarely  failed  to  obtain  a  com- 
plete cure  by  this  method  of  treatment.  Kelsey  also  claims  to  have 
had  the  most  satisfactory  results.  The  English  surgeons,  Cripps,  Ailing- 
ham,  and  Ball,  all  speak  highly  of  the  method;  and  so  far  as  obtaining 
an  immediate  enlargement  of  the  rectal  caliber,  allowing  the  free  pas- 
sage of  fgeces,  and  giving  to  the  patient  relief  from  symptoms  of  ob- 
struction are  concerned,  the  operation  is  satisfactory;  but  in  the  author's 
experience,  the  only  permanent  cures  by  it  have  been  in  a  few  cases  of 
annular  or  falciform  contraction  low  down  in  the  rectum. 

It  should  be  borne  in  mind  that  in  certain  cases  where  fistulous 
tracts  extend  around  the  stricture,  opening  above  it  into  the  rectum, 
and  below  either  upon  the  skin  or  into  the  anus,  these  tracts  may  be 
laid  freely  open,  and.  thus  the  stricture  incised  without  doing  pos- 
terior proctotomy.  The  more  incisions  that  are  made  the  more  like- 
lihood will  there  be  of  sepsis;  nevertheless,  all  the  fistulous  tracts  and 
burrowings  should  be  laid  open,  and  the  parts  protected  as  well  as  possi- 


FiG.    173— Multiple    Strictcre    or    the 
Eectlii. 


506  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

ble  by  antiseptic  dressings  and  frequent  irrigations.  When  these  pre- 
cautions are  carried  out,  there  is  not  a  great  deal  of  danger  of  sepsis, 
and  eases  of  erysipelas  and  diffuse  periproctitis  are  seldom  seen.  The 
objections  to  the  operation,  however,  remain:  recurrence  is  rapid  and 
frequent,  there  is  a  certain  amount  of  incontinence  for  an  indefinite 
period  of  time,  healing  is  slow,  and  the  patient  can  never  expect  to 
discontinue  the  use  of  some  dilating  instrument.  (Lachowski,  Carre, 
Quenu  and  Hartmann.) 

Where  the  stricture  is  very  tight,  the  operation  is  sometimes  done 
in  two  steps,  first  dividing  the  sphincters  and  the  rectal  wall  up  to 
the  stricture,  and  checking  the  hsemorrhage  in  these  parts.  Later  the 
stricture  itself  is  incised  by  the  introduction  of  a  grooved  sound  for  a 
guide  to  the  bistoury  where  it  is  impossible  to  introduce  the  finger  for 
this  purpose.  This  is  simply  a  matter  of  detail,  however,  and  while  it 
may  be  a  wise  precaution  it  is  not  necessary. 

Excision. — As  far  back  as  1825  Lisfranc  excised  the  rectum  for  stric- 
ture. The  reports  of  these  cases  by  Carre  (Thesis,  1893)  clearly  indicate 
the  inflammator}'  or  syphilitic  nature  of  two  of  them  which  were  sup- 
posed to  have  been  carcinomatous.  Glaeser  (Archiv  f.  klin.  Chir.,  1867- 
'68,  Bd.  ix,  p.  509)  in  1864  excised  a  cicatricial  stricture  of  the  rectum. 
The  patient  made  a  good  recovery,  but  the  stricture  recurred,  and  two 
years  later  he  was  compelled  to  do  a  colotomy  above  the  site  of  the  stric- 
ture. From  this  period  on  to  1890  there  were  a  few  isolated  cases  re- 
ported in  which  the  operation  was  performed. 

The  statistics  and  reports  are  somewhat  contradictory  owing  to  the 
fact  that  writers  and  operators  did  not  distinguish  between  resection 
and  excision  and  between  the  different  types  of  strictures.  Thus  Quenu 
and  Hartmann  claim  that  the  first  attempt  at  extirpation  of  a  syphi- 
litic stricture  in  France  was  made  by  Quenu  in  July,  1890,  and  was 
followed  by  the  operations  of  Eichelot,  Terrier,  and  others.  On  the 
other  hand,  Carre  gives  the  credit  to  ]\Iarehant,  and  states  that  Dessault 
had  done  it  as  early  as  1828.  Pinault  (These,  Paris,  1829)  is  also 
known  to  have  excised  the  lower  end  of  the  rectum  for  stricture  in 
1826.  While  these  early  operations  are  put  down  under  the  heading 
of  cancer,  Carre  says  that  it  is  clearly  apparent  from  the  cases  cited  by 
Pinault  that  some  of  them  at  least  were  syphilitic.  In  the  discussion 
before  the  Societe  de  Chirurgie  of  Paris  in  1891,  Eichelot  stated  that 
the  operation  of  excision  for  syphilitic  stricture  of  the  rectum  was  a 
success;  that  whatever  the  method,  "  the  stricture  is  cured  forever  with- 
out infirmity."  Quenu  indorsed  this  statement,  at  the  time,  but,  as 
will  be  seen  later  on  in  his  own  statistics,  its  truth  is  questionable. 

Strictures  of  the  rectum  may  be  removed  by  the  perineal  or  sacral 
routes. 


STRICTURE   OF   THE  RECTUM      ■  507 

Perineal  Method. — The  perineal  raethod  is  applicable  to  those  within 
6  centimeters  (2f  inches)  of  the  anus.  If  the  sphincters  and  the  anus 
are  involved,  the  whole  anal  circumference  is  dissected  out  and  the 
rectum  amputated  at  the  upper  level  of  the  stricture;  if  the  constriction 
is  above  these  parts,  the  operation  may  be  performed  in  several  ways. 
First,  the  sphincters  are  incised  in  the  median  line  back  to  the  tip  of 
the  coccyx;  a  circular  incision  through  the  entire  thickness  of  the  gut 
is  then  made  around  the  rectum  just  above  the  internal  sphincter;  the 
flaps  containing  the  muscles  are  then  drawn  to  each  side  and  the  rectum 
is  dissected  out  to  the  upper  level  of  the  stricture;  if  possible  without 
too  much  hgemorrhage  or  too  prolonged  dissection,  the  gut  may  be  dis- 
sected farther  upward,  dragged  down  and  reunited  to  the  edges  of  the 
mucous  membrane  covering  the  sphincter  muscles.  If  the  amount  of  gut 
removed  renders  this  impossible,  the  wound  may  be  left  open  to  heal 
by  granulation,  a  large-sized  rubber  tube  being  introduced  into  the 
caliber  of  the  gut  above  for  the  purpose  of  conveying  outside  of  the 
wound  as  much  feecal  material  as  possible.  If  it  has  been  possible  to 
drag  the  gut  down  and  suture  it  to  the  mucous  membrane,  then  it  is 
wise  to  suture  the  sphincter  muscles  together  where  they  were  divided, 
otherwise  this  should  not  be  done.  Second,  an  elliptical  incision  is 
made  embracing  -f  of  the  posterior  circumference  of  the  anus,  and 
deep  enough  to  go  above  the  sphincters;  this  flap  is  dissected  forward, 
thus  amputating  the  rectum  above  the  muscles;  the  rectum  is  then  dis- 
sected out  up  to  the  superior  limits  of  the  stricture  and  cut  off';  if 
possible,  the  gut  is  then  dragged  dovm  and  reunited  to  the  flap,  including 
the  sphincters,  and  the  latter  is  sutured  in  position.  If  this  is  impossible, 
an  opening  is  made  on  the  side  of  the  coccys  and  an  artificial  anus 
formed  at  this  point.  After  the  patient's  general  condition  has  im- 
proved from  the  relief  given  by  this  operation,  the  gut  may  be  dissected 
out  either  by  the  sacral  method  or  through  the  wound  alongside  of  the 
coccyx,  and  brought  down  and  sutured  to  the  flap,  which,  having  been 
allowed  to  lie  loose  in  the  perineal  wound,  will  need  to  be  dissected  up 
and  freshened  in  order  to  obtain  a  suitable  place  for  the  reattachment 
of  the  gut. 

These  are  the  methods  of  choice  in  strictures  which  do  not  extend 
more  than  6  centimeters  (2f  inches)  above  the  anal  margin.  AMien 
higher  than  this  the  sacral  route  is  more  satisfactory. 

The  Sacral  Method. — The  sacral  method  consists  in  some  modification 
of  the  Kraske  operation  for  excision  of  the  rectum.  ~\^liere  the  stricture 
is  within  the  first  10  centimeters  (3|  inches)  there  is  no  necessity  to 
remove  am-fhing  more  than  the  coccyx  in  order  to  excise  it.  Abundant 
room  can  be  obtained  by  this  procedure. 

TThere  it  extends  higher  than  this,  it  mav  be  necessarv  to  cut  off  a 


508  THE  AJs^CS,   RECTUM,  AND   PELVIC   COLON 

triangular  jriece  from  the  sacrum,  thus  giving  a  wider  operative  field, 
or  to  adopt  Eydygier's  method,  in  which  the  bones  are  all  preserved 
and  restored  to  their  normal  position,  and  thus  the  floor  of  the  pelvis 
is  not  impaired. 

Having  exposed  the  rectum  by  this  means,  it  should  be  clamped  with 
long-bladed  forceps  in  order  to  control  bleeding,  and  then  the  dissection 
should  be  carried  as  far  up  as  necessary  to  remove  the  entire  stricture 
and  bring  the  portion  of  the  rectum  above  the  stricture  down  to  the 
healthy  tissue  below  it.  By  proceeding  in  this  manner,  if  it  is  necessary 
to  open  the  peritonaeum,  there  will  be  little  danger  from  infection, 
inasmuch  as  the  gut  will  not  have  been  opened  until  after  all  this  dis- 
section is  completed.  Having  loosened  the  gut  as  high  up  as  is  neces- 
sary, the  peritoneal  cavity  should  be  closed  either  by  sutures  or  by  tam- 
poning with  iodoform  gauze.  The  gut  should  then  be  cut  off  through 
the  healthy  tissue  above  the  stricture,  and  the  diseased  section  dissected 
out  from  above  downward. 

The  point  in  this  technique  is,  first,  to  control  the  haemorrhage,  which 
comes  largely  from  the  superior  ha?morrhoidal  vessels;  and,  secondly, 
to  accomplish  all  the  intraperitoneal  dissection  and  close  this  cavity 
before  the  gut  is  opened,  thus  avoiding  the  greatest  danger  from  sepsis 
in  this  operation.  Having  dissected  out  the  stricture  down  to  the 
healthy  tissue  below^  it  should  be  cut  off  and  the  two  ends  of  the  re- 
maining gut  united  by  end-to-end  suture,  the  Murphy  button,  or  by 
invaginating  the  upper  end  through  the  lower,  and  suturing  it  outside 
of  the  anus.  The  bone-flap  is  then  sutured  back  in  its  normal  position 
with  silkworm  gut  and  the  external  wound  closed,  with  the  exception  of 
its  lower  angle,  which  is  left  open  for  drainage.  The  technique  of  this 
operation  is  fully  described  in  the  chapter  on  Extirpation  of  the  Eectiun. 
Where  the  stricture  is  in  the  pelvic  colon  it  should  be  removed  by  the 
abdominal  route,  with  end-to-end  union,  as  is  done  in  cancer  of  this 
region. 

Results. — After  the  reports  of  Eichelot,  Quenu,  and  Carre  in  France, 
Kelsey  and  Weir  in  Xew  York,  and  Alberan  and  Kraske  in  Germany, 
excision  was  hailed  with  great  enthusiasm  as  having  solved  the  treatment 
of  rectal  stricture.  The  stricture  being  removed,  the  obstruction  oblit- 
erated, the  patient  was  cured,  notwithstanding  the  fact  that  they  suffered 
frequently  from  small  fistulas  and  perineal  phlegmons.  The  mortality 
from  the  operation  in  the  beginning  was  comparatively  small,  about  10 
per  cent.  Longer  observation  of  the  cases  began  to  show  a  recurrence 
of  the  stricture  even  in  a  worse  form  than  previously,  and  the  enthu- 
siasm subsided.  Lachowski  (These,  Paris,  1894r-'95),  in  a  careful  study 
of  this  subject,  shows  that  the  recurrences  after  this  method  are  almost 
as  large  in  proportion  as  after  complete  proctotomy.    Quenu  and  Hart- 


STRICTURE   OP   THE   RECTUM  509 

mann  {op.  cit.,  p.  '6'Z5)  give  a  detailed  account  of  35  cases,  in  wiiicli  there 
were  4  deaths  directly  due  to  the  operation — a  mortality  of  11.43  per 
cent.  Of  the  remaining  cases^  1  succumbed  to  pneumonia  in  about 
six  months,  1  was  at  the  time  of  the  report  in  a  dying  condition  from 
tuberculosis,  and  10  were  lost  to  view.  In  the  19  cases  which  they  were 
able  to  observe  for  some  months  to  four  years,  the  results  were  as  follows: 
One  had  been  compelled  to  submit  to  a  colotomy,  the  stricture  having 
returned;  18  others  were  suffering  from  rectitis  and  suppuration  suffi- 
cient to  compel  them  to  wear  napkins;  1  had  a  stercoral  fistula;  8  suf- 
fered from  incontinence  of  gas  and  liquid  f^ces;  and  6  had  a  clear 
recurrence  of  the  stricture.  In  8  only  were  the  faecal  movements  nor- 
mal. It  must  not  be  presumed,  however,  that  the  8  cases  were  radically 
cured,  for  the  authors  state  that  they  all  suffered  more  or  less  from 
suppuration,  a  thickening  of  the  mucous  membrane,  and  a  rigid,  cylin- 
drical and  abnormal  condition  of  the  rectum. 

Lapointe  (La  presse  medicate,  1898,  p.  153),  in  reviewing  the  subject, 
collected  69  cases  with  10  operative  deaths  and  1  due  to  septic  infection 
of  the  sacral  wound  shortly  afterward,  thus  giving  a  mortality  of  14.5 
per  cent.  Forty-seven  were  done  by  the  perineal  method  with  8  deaths, 
a  mortality  of  17.3  per  cent;  20  by  the  sacral  method  with  2  deaths, 
mortality  10  per  cent;  and  2  by  the  vaginal  method,  in  both  of  which 
the  results  were  good.  In  addition  to  the  10  operative  deaths,  4  others 
died  within  the  first  year,  thus  leaving  55  cases.  Of  these,  31  were 
observed  for  less  than  one  year  and  24  for  more.  In  the  24  cases  there 
was  a  recurrence  in  12,  or  50  per  cent.  In  38  cases  done  by  the  perineal 
method,  19  had  more  or  less  incontinence.  In  15  done  by  the  Eo-aske 
method,  incontinence  was  noticed  six  times;  thus  in  the  55  cases  incon- 
tinence has  followed  in  25.  Prolapse  occurred  in  3  cases  done  by  the 
Kraske  method,  but  no  cases  of  this  are  reported  in  the  operations  done 
by  the  perineal  route.  It  is  reasonable  to  suppose  that  the  majority  of 
the  cases  which  were  lost  to  view  were  successful,  inasmuch  as  they  were 
in  favorable  conditions  when  last  seen.  Therefore,  one  may  state  that, 
barring  a  certain  amount  of  inconvenience  due  to  ulceration,  small 
fistulas,  or  incontinence,  50  per  cent  of  these  cases  have  been  practically 
cured.  These  results,  while  not  satisfactory,  certainly  are  an  improve- 
ment over  the  old  methods  of  treating  stricture  by  internal  and  complete 
proctotomy. 

Proctoplasty. — WTiere  there  has  been  great  destruction  of  tissue 
around  the  margin  of  the  anus  or  the  lower  portion  of  the  rectum,  fol- 
lowed by  large,  dense  cicatrices,  it  will  sometimes  be  impossible  to 
restore  the  caliber  of  the  gut  without  resorting  to  some  form  of  plastic 
operation.  IsTo  rule  can  be  laid  down  for  these  conditions.  The  ingenu- 
ity of  the  surgeon  will  be  put  to  the  test  in  each  individual  case. 


510 


THE   ANUS,  RECTUM,   AND   PELVIC   COLON 


Krouse,  of  Cincinnati,  has  reported  an  interesting  example  of  what 
ma}^  be  clone  by  this  method  in  the  case  of  an  extensive  stricture  of  the 
anus  following  a  burn.  He  dissected  up  a  large  triangular  flap  from 
the  buttock,  swung  it  around  into  the  space  from  which  he  removed 
the  extensive  cicatrix,  and  sutui'ed  it  in  position. 
The  parts  healed  promptly,  and  the  final  result  was 
a  comparatively  normal  anus. 

Williams,  of  Melbourne,  enlarged  the  caliber 
by  a  plastic  operation  entirely  within  the  rectum. 
He  incised  an  annular  stricture  from  above  down- 
ward under  rigid  antiseptic  precautions.  The  in- 
cision was  then  sutured  obversely  in  its  long  axis 
so  that  the  wound  was  made  to  extend  horizontally 
around  the  rectum.  By  this  ingenious  procedure 
the  caliber  of  the  gut  was  increased  by  just  the 
length  of  the  wound,  and  the  immediate  result 
was  a  relief  of  the  stricture.  The  case  was  re- 
ported within  a  few  months  after  healing,  and 
therefore  the  permanency  of  cure  can  not  be 
vouched  for. 

Swartz  (Presse  medicale,  1894,  p.  304)  modified 
this  procedure  by  approaching  the  rectum  from  the 
outside  through  an  incision  made  between  the  coc- 
cyx and  anus.    He  incised  the  gut  longitudinally, 
and  sutured  its  walls  together  after  the  manner  of 
Williams.    The  wound  in  the  skin  was  left  open  for 
drainage,  and  a  large-sized  drainage-tube  was  in- 
troduced into  the  rectum  to  facilitate  the  escape 
of  gases  and  liquid  f»cal  matter.     This  case  was 
also  reported  within  a  month  after  the  operation, 
and  the  ultimate  result  can  not  be  stated;  it  is  mentioned  simply  because 
it  has  been  referred  to  a  number  of  times  in  literature  as  having  cured 
the  stricture. 

Skin-grafting  and  plastic  operations  about  the  margin  of  the  anus 
are  practical  methods  known  to  every  surgeon,  and  where  there  is  an 
intractable  granulation  associated  with  large  cicatricial  deposits,  one 
may  greatly  improve  the  patient's  condition  by  employing  these. 

Lateral  Entero-anastomosis. — Bacon  (]\rathews's  Med.  Quarterly,  vol. 
i,  p.  1,  1894)  has  described  a  most  ingenious  method  for  the  relief  of 
stricture  of  the  rectum  when  situated  above  the  sphincteric  region.  It 
consists  in  bringing  a  normal  loop  of  the  sigmoid  down  and  anastomosing 
it  with  the  rectum  below  the  stricture,  as  follows:  After  the  patient  has 
been  properly  prepared  and  etherized,  he  is  placed  in  the   extreme 


Fig.  1V4.  —  Trocar  for 
Insertion  of  Female 
Segment  of  Murphy 
Button  in  Bacon's  Op- 
eration FOR  Stricture 

OF  THE   KeCTUM. 


STRICTURE   OF  THE  RECTUM 


511 


Trendelenburg  posture,  and  an  abdominal  section  is  made  from  the 
pubis  to  the  umbilicus.  The  sigmoid  is  then  folded  downward  until 
it  reaches  well  below  the  stricture,  and  thus  the  point  at  which  the 
anastomosis  is  to  be  made  is  measured.  It  is  then  dra^^^l  well  out  of  the 
abdomen,  and  with  Murphy  clamps  above  and  below  this  point,  a 
longitudinal  incision  is  made  into  the  gut  between  them  and  the  male 
half  of  a  Murphy  button  secured  in  this  incision.  After  having  scari- 
fied the  peritoneal  surfaces  of  the  sigmoid  and  the  rectum,  the  female 
half  of  the  button  is  introduced  into  the  wall  of  the  latter  in  the  fol- 
lowing manner:  an  instrument  carrying  a  short  trocar  (Fig.  174),  which 
passes  through  the  hole  in  the  button,  is  pushed  up  into  the  rectum 
by  an  assistant  and  pressed  against  the  anterior  wall  of  the  gut  just 
below  the  site  of  the  stricture,  while  the  operator,  with  his  hand  in  the 
abdominal  cavity,  presses  down  upon  the  trocar  and  causes  it  to  pene- 
trate the  wall,  carrying  the  neck  of  the  button  along  with  it.     The  two 


Fig.  175. — Lateral  Entero-anastomosis  (Bacon). 
A,  mesorectum. 

ends  of  the  button  are  then  seized  by  the  operator  and  approximated, 
and  the  anastomosis  is  complete.  Two  or  three  sutures  are  placed  in  the 
peritoneal  layer  of  the  gut  (Fig.  175)  in  order  to  fortify  the  anastomosis 
made  by  the  button  and  also  to  prevent  any  loops  of  the  small  intestine 
coming  in  between  those  of  the  sigmoid  flexure  and  the  rectum.  If  the 
operation  has  been  carefully  performed,  no  feecal  extravasation  or  leak- 


512 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


Fig.  176.  —  Clamp  introduced  through  Stricture  and 
Anastomotic  Opening  in  order  to  widen  the  Caliber 
OF  the  Gut  in  Bacon's  Operation. 


jige  will  have  occurred  in  the  abdominal  cavity,  and  the  latter  may  then 
be  permanently  closed.  The  button  will  be  expelled  in  five  to  seven 
days,  after  which  an  enema  may  be  given  by  the  rectum,  and  the  colon 
thoroughly  washed  out.     After  this  a  long  clamp  is  inserted  through 

the  anus,  one  blade  of 
which  is  introduced 
through  the  button- 
hole into  the  sigmoid 
while  the  other  extends 
through  the  stricture 
and  upward  into  the 
rectum  (Fig.  176).  The 
clamp  is  then  firmly 
closed,  thus  embracing 
the  stricture  in  its  bite. 
On  each  succeeding 
day  the  handles  of  the 
clamp  are  closed  little 
by  little  until  the  sa?ptum  is  completely  severed,  which  usually  oc- 
curs upon  the  third  day.  By  this  means  the  caliber  of  the  gut 
will  be  increased  to  that  of  the  sigmoid  fiexure  plus  the  former  cali- 
ber of  the  stricture.  Bacon  states  that  where  the  stricture  is  low 
down  the  operation  may  be  done  by  the  sacral  method.  The  operation 
has  no  advantages  over  resection  and  end-to-end  union  in  strictures  of 
the  sigmoid  flexure.  He  emplo3^ed  this  ingenious  method  upon  4  dogs, 
2  by  the  abdominal  and  2  by  the  sacral  method,  and  all  were  successful; 
later  on  he  applied  it  with  success  in  an  old,  specific,  rectal  stricture 
in  a  woman. 

Colotomy.- — In  non-malignant  strictures  colotomy  is  generally  looked 
upon  as  a  last  resort,  one  wdiich  patients  and  surgeons  avoid  until  ob- 
struction is  imminent,  and  until  recently  the  operation  has  only  been 
done  when  this  has  occurred  or  the  pain  has  become  unbearable. 

As  early  as  1824  Martland  performed  a  left  iliac  colotomy  to  over- 
come obstruction  due  to  a  stricture,  and  thus  prolonged  his  patient's 
life  for  more  than  seventeen  years  (Edinburgh  Med.  and  Surg.  Jour., 
vol.  xxiv,  p.  271). 

In  1865  Curling  did  a  lumbar  colotomy  for  the  first  time  with  the 
deliberate  intent  of  preventing  obstruction  in  an  incurable  stricture 
(Amer.  Jour,  of  Med.  Sci.,  1873). 

Allingham  performed  the  operation  in  1867,  and  Glaeser  (Archiv  f. 
klin.  Chir.,  Berlin,  1867-'68,  p.  509)  operated  upon  a  woman  for  intes- 
tinal obstruction  due  to  a  stricture  which  he  had  already  excised  and 
which  had  recurred.    Twenty  years  later  {ihid.,  1887,  vol.  xxxiv,  p.  459) 


STRICTURE  OF  THE  RECTUM  513 

lie  had  the  unusual  opportunity  of  making  an  autopsy  upon  the  body 
of  the  patient,  establishing  clearly  the  specific  nature  of  the  original 
stricture,  and  showing  that  the  pelvic  colon  and  rectum  had  been  re- 
duced to  nothing  more  than  a  long,  narrow,  fibrous  cord  perforated  by 
a  small  canal  which  would  admit  only  the  finest  sounds,  and  was  sur- 
rounded by  inflammatory  tissue.  He  says  the  "  cavity  of  the  cord  is 
lined  with  a  membrane  which  seems  more  like  a  serous  than  a  mucous 
membrane/'  The  interesting  point  of  this  case  is,  that  notwithstanding 
the  strictured  portion  of  the  gut  below  the  artificial  anus  had  been 
absolutely  devoid  of  functional  activity  for  nearly  twenty  years,  it  still 
remained  patulous. 

From  this  period  forward  operators  in  America,  England,  Germany, 
and  France  (Hochenegg,  x4rb.  IT.  Hahresh.  d.  K.  K.  ersten  chirur.  Uni- 
versitats  Klinik  zu  Wien,  1888-'89,  p.  122;  Konig,  Berlin,  klin.  Woch., 
1887,  p.  17;  Hahn,  Archiv  f.  klin.  Chir.,  Berlin,  1883,  Bd.  xxix,  p.  395; 
and  Mason,  Amer.  Jour,  of  Med.  Sci.,  Philadelphia,  1873,  vol.  ii,  p.  354) 
have  more  and  more  resorted  to  colotomy  in  cases  of  stricture  of  the 
rectum.  Excellent  results  have  been  obtained,  and  long  periods  of  life 
have  followed  the  operation  in  cases  of  non-malignant  stricture.  In  a 
case  of  the  writer's,  the  patient  survived  eleven  years  after  an  artificial 
anus  was  made  for  an  intestinal  obstruction  due  to  syphilitic  stricture. 

Where  the  stricture  is  inoperable  by  excision  or  proctotomy,  when 
it  has  recurred  after  these  operations  or  where  obstruction  takes  place, 
there  is  no  question  as  to  the  advisability  of  this  operation.  Recently 
some  operators,  recognizing  the  fact  that  by  functional  rest  and  local 
and  constitutional  treatment,  much  may  be  done  to  promote  the  ab- 
sorption and  disappearance  of  a  stricture  of  the  rectum,  have  under- 
taken the  cure  by  making  temporary  artificial  ani,  side-tracking  the 
fa?cal  current,  thus  giving  the  opportunity  of  treating  the  strictured 
canal  from  both  ends.  By  this  means  complete  drainage  is  obtained,  the 
distention  and  irritation  are  stopped,  obstruction  of  the  faecal  current 
at  the  point  of  stricture  is  avoided,  and  the  dangers  of  infection  from 
the  intestinal  contents  are  practically  eliminated  in  case  it  is  necessary 
to  excise  the  gut  or  dilate  the  stricture. 

Lowson  and  Kammerer  were  among  the  first  fo  employ  this  method 
as  a  preliminary  procedure  for  the  extirpation  of  non-malignant  stric- 
ture, and  Thiem  (Verhandlungen  d.  deutsch.  Gesellsch  f .  Chir.,  Berlin, 
1892,  p.  46)  first  employed  it  as  a  preliminary  to  the  treatment  of  stric- 
ture in  the  sigmoid  by  gradual  dilatation  with  bougies.  After  the 
stricture  was  completely  dilated  and  apparently  cured,  he  closed  the 
artificial  anus,  and  up  to  the  time  of  his  report  the  patient  had  remained 
perfectly  well,  the  intestines  having  resumed  all  their  functions. 

In  1897  the  author  made  an  artificial  anus  in  an  Indian  woman  aged 
33 


514  THE  ANUS,  RECTUM,  AND  PELTIC  COLON 

t\veut3'-two,  in  the  workhouse  hospital  of  this  city,  with  the  view  of 
treating  an  extensive  syphilitic  ulceration  and  stricture  of  the  rectum 
that  occurred  within  the  first  year  after  her  infection.  The  stricture 
was  situated  at  3|  inches  from  the  margin  of  the  anus,  and  barely  ad- 
mitted the  tip  of  the  index  finger.  The  mucous  membrane  of  the  lower 
anterior  surface  of  the  rectum  was  entirely  destroyed,  and  it  was  impos- 
sible to  determine  the  extent  to  which  the  ulceration  extended  above 
the  stricture.  With  a  view  to  treating  the  stricture  and  possibly  ex- 
cising it,  a  temporary  artificial  anus  was  made  in  the  highest  point 
of  the  sigmoid  flexure.  Under  the  use  of  antispecific  medication,  anti- 
septic irrigation,  and  persistent  dilatation,  the  ulceration  healed,  the 
caliber  of  the  gut  was  gradually  increased,  and  finally  resumed  almost 
a  normal  appearance.  The  artificial  anus  was  closed  by  the  extra-peri- 
toneal method,  and  at  the  time  that  the  patient  left  the  hospital  six 
months  later,  her  bowels  moved  regularly,  there  was  no  discharge,  and 
so  far  as  could  be  observed  she  was  perfectly  well. 

The  same  method  was  practised  in  the  Polyclinic  Hospital  in  189-i. 
In  this  patient,  however,  the  stricture  was  of  a  dense,  hard,  cicatricial 
nature,  and  it  finally  became  necessary  to  incise  it  before  any  material 
increase  in  the  caliber  of  the  gut  could  be  obtained  or  healing  of  the 
ulcer  induced.  After  complete  posterior  proctotomy,  the  caliber  of  the 
gut  was  restored  and  the  ulceration  healed,  but  the  dense,  hard,  cica- 
tricial tissue  remained,  and  could  be  easily  felt  by  the  finger.  My 
impression  was  that  this  would  be  likely  to  recontract,  and  much  more 
rapidly  if  the  faecal  current  were  turned  again  into  its  natural  channel. 
This  was  explained  to  the  patient,  and  as  he  had  learned  to  manage 
the  artificial  anus  comfortably,  he  declined  to  have  it  closed.  He  dis- 
appeared from  view  after  this,  going  upon  the  road  as  a  traveling  sales- 
man, and  the  last  heard  of  him  (some  two  years  later)  was  that  he  was 
perfectly  well  and  enjoying  life. 

In  1898  the  author  performed  the  operation  for  the  treatment  of 
stricture  for  the  third  time  in  the  Almshouse  Hospital  of  this  city.  This 
patient  had  been  operated  upon  for  supposed  cancer  of  the  rectum  some 
two  years  previous.  She  suffered  a  great  deal  of  pain,  and  there  was 
a  large  ulceration  in  her  rectum  which  did  not  appear  malignant. 

A  temporary  artificial  anus  was  made,  and  the  treatment  by  irriga- 
tion and  dilatation  of  the  stricture  was  begun.  After  three  months 
the  caliber  of  the  gut  seemed  practically  restored,  and  upon  the  pa- 
tient's urgent  request  the  artificial  anus  was  closed  in  May,  1899.  In 
January,  1900,  the  patient  returned  to  the  hospital  suffering  from  con- 
stipation, difficulty  in  obtaining  a  movement  of  the  bowels,  pain  in  the 
sacrum,  and  more  or  less  purulent  discharge.  An  examination  of  the 
rectum  revealed  the  fact  that  the  stricture  had  recurred,  this  time  more 


STRICTUEE   OF   THE   RECTU:\r  515 

dense  and  fibrous  than  before.  For  the  third  time  in  her  case  colotomy 
was  done  and  a  jDermanent  artificial  anus  made,  after  tlie  method  of 
Bailey.  For  some  reason  or  other  the  patient  had  a  severe  haemorrhage 
from  one  of  the  mesenteric  vessels  two  hours  after  the  operation,  and 
sh.e  came  near  losing  iter  life  from  it.  She  still  remains  in  the  hospital 
at  the  present  day;  she  is  obdurate  with,  regard  to  the  use  of  bougies, 
and  consequently  the  stricture  has  not  received  the  attention  which,  it 
should.  Notwithstanding  this,  the  fibrous  stricture  has  greatly  sof- 
tened, showing  the  effect  of  local  treatment  and  functional  rest  upon 
these  conditions.  TVith  this  limited  experience  the  author  is  not  pre- 
pared to  make  any  very  positive  assertions  with  regard  to  the  effect 
of  colotomy  as  a  curative  agent  in  stricture  of  the  rectum,  but  from 
these  cases  and  the  experiences  of  Thiem  and  Lowson  it  is  thought 
that  we  may  hold  out  to  patients  afflicted  with  strictures  and  excess- 
ive ulceration  of  the  rectum  a  reliable  hope  of  relief  from  suffering, 
and  the  possibility  of  a  cure,  with  eventual  restoration  of  the  fsecal 
current  to  its  normal  course. 

Resume. — In  a  somewhat  detailed  manner  the  different  methods  for 
the  treatment  of  stricture  have  been  reviewed^  and  no  very  positive 
preference  has  been  expressed  for  one  over  another.  The  fact  is  that 
up  to  the  present  time  a  satisfactory  treatment  for  this  condition  has 
not  been  devised.  The  dangers  of  sepsis  and  hasmorrhage  in  internal 
proctotomy  would  certainly  contraindicate  its  use  in  the  large  majority 
of  cases.  Complete  proctotomy,  while  less  dangerous  so  far  as  sepsis  and 
haemorrhage  are  concerned,  has  the  disadvantages  that  it  results  in  pro- 
tracted ulceration,  prolonged  incontinence,  and  recurrence  practically 
always  takes  place  unless  the  use  of  bougies  is  continued  throughout 
life.  E"otwithstanding  these  disadvantages,  the  operation  is  the  least 
dangerous  method  for  the  radical  cure  of  the  disease,  and  often  affords 
the  patient  much  relief  for  a  considerable  time.  ]\Iany  cases  are  re- 
ported in  which  it  has  resulted  in  a  radical  cure,  but  such  results  can 
not  be  looked  forward  to  with  any  degree  of  confidence  in  the  large 
majority  of  cases. 

The  favorable  results  of  the  first  few  excisions  done  for  non-malig- 
nant stricture  led  many  to  believe  that  the  radical  cure  of  this  disease 
had  at  last  been  found.  The  author  has  been  able  to  gather  from 
private  communications  and  the  journals  25  cases  in  addition  to  those 
collected  by  Lapointe  and  Quenu  and  Hartmann,  thus  making  a  total 
of  94  cases  of  resection  with  14  deaths,  a  mortality  of  16  per  cent. 
"When  the  fact  is  recognized  that  all  strictures,  whether  malignant  or 
non-malignant,  prove  fatal  in  the  course  of  time  unless  properly  treated 
or  removed,  this  mortality  should  not  offer  any  great  argument  against 
the  performance  of  an  operation  which  promises  a  radical  cure.     Un- 


516  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

fortunately  the  results  thus  far  obtained  by  resection  do  not  justify 
the  statement  that  a  radical  cure  will  be  obtained  in  the  majority  of 
cases. 

Investigation  shows  that  in  one-half  of  the  resections  for  non- 
malignant  stricture  of  the  rectum  there  has  been  a  recurrence  in  situ, 
whether  the  stricture  has  been  of  a  specific  or  of  a  simple  inflammatory 
nature.  Assuming,  however,  that  of  the  cases  which  have  survived  the 
operation  a  radical  cure  may  be  obtained  in  one-half  of  them,  it  would 
still  be  necessary  to  conclude  that  this  method  is  superior  to  any  which 
is  known  for  the  treatment  of  stricture.  Nevertheless,  in  cases  with 
extensive  ulceration  and  suppuration,  this  operation  is  very  dangerous 
to  life,  and  the  formation  of  a  temporary  artificial  anus,  followed  by  local 
treatment  and  dilatation,  is  a  far  safer  procedure,  and  will  accomplish 
just  as  good  results  in  a  large  number  of  cases  of  this  type  as  attempts 
at  resection  or  proctotomy. 

After  the  ulceration  and  suppuration  have  been  controlled,  and  it 
is  found  that  the  stricture  persists,  or  has  a  tendency  to  retract,  resec- 
tion may  be  done  without  so  much  danger  of  infection,  and  with  a 
greater  probability  of  inmiediate  union  between  the  sutured  ends.  In 
brief,  a  temporary  artificial  anus,  with  gradual  dilatation  and  local  treat- 
ment, and,  if  necessary  and  practicable,  the  eventual  resection  of  the 
stricture,  seem  to  furnish  the  most  rational  as  well  as  the  safest  method 
of  treatment. 


CHAPTER   XIV 
CONSTIPATION,    OBSTIPATION,   AND  FMGAL  IMPACTION 

Constipation  consists  in  the  passage  of  insufficient  amounts,  or 
the  abnormally  prolonged  retention,  of  fscal  material  in  the  intestinal 
canal.  A  healthy  individual  passes  upon  an  average  6  ounces  of  faeces 
in  twenty-four  hours.  These  figures,  however,  are  only  relative;  the 
amount  of  fsecal  material  depends  not  only  upon  the  food  ingested,  but 
the  quality  of  the  food  and  the  activity  of  the  digestive  functions. 
Active,  energetic  individuals  living  an  outdoor  life  consume  large  quan- 
tities of  food  of  a  mixed  variety,  and  therefore  their  f^cal  dejections 
are  much  greater  than  those  of  individuals  who  lead  a  sedentary  life 
and  consume  small  quantities  of  a  limited  dietary.  Farmers  and  other 
individuals  who  live  chiefly  upon  vegetables,  cereals,  and  the  coarser 
articles  of  food,  pass  larger  quantities  of  faeces  than  the  more  pampered 
classes  who  consume  small  quantities  of  concentrated  and  refined  foods, 
in  which  there  is  a  minimum  amount  of  indigestible  detritus.  Con- 
stipation exists  in  both  of  these  classes,  but  it  can  not  be  based  upon 
the  amount  of  fseces  passed.  So  also  is  the  period  of  the  retention  of 
fgecal  material  in  the  intestine  comparative.  It  requires  from  fifteen  to 
twenty  hours  for  the  food  to  pass  through  the  intestinal  canal.  The 
ordinary  assumption  based  upon  these  figures  is  that  every  normal  indi- 
vidual should  have  a  stool  of  adequate  quantity  once  in  twenty-four 
hours.  So  imbued  with  this  idea  are  the  laity  in  general,  that  one  who 
does  not  succeed  in  having  such  a  passage,  or  whose  passages  do  not 
appear  to  be  normal  in  quantity,  quality,  color,  or  consistence,  immedi- 
ately considers  himself  the  victim  of  constipation,  and  begins  to  take 
drugs  or  enemata  to  remedy  the  condition. 

Fsecal  movements,  while  more  or  less  involuntary,  are  matters  of 
habit  and  education  to  a  large  extent.  One  can  accustom  his  bowels 
to  move  twice  a  day,  once  a  day,  or  once  in  three,  four,  or  five  days, 
and  ordinarily  an  individual  whose  fsecal  periods  are  regular  every  three 
days  is  just  as  healthy  as  another  whose  bowels  move  twice  a  day.  A 
child  may  be  educated  in  infancy  to  have  fsecal  passages  twice  a  day, 
and  this  will  be  maintained  as  long  as  there  are  no  pathological  condi- 
C  517 


518  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

tions  and  no  mental  diversions  or  preoccupations  to  interfere  with 
attention  to  the  periodic  calls.  This  periodicity  can  be  established  in 
any  healthy  intestine,  and  often  establishes  itself  unconsciously  in  ac- 
cordance with  the  occupations  and  habits  of  the  individual,  as  is  shown 
in  the  following  case: 

J.  A.,  a  railroad  conductor,  had  a  night  and  a  day  run  from  Philadelphia  to 
Chicago,  leaving  one  morning  and  arriving  the  next;  on  his  return  trip  lie  left  at 
night  and  arrived  the  following  night;  thus  he  was  at  home  every  third  night  and 
every  third  day.  Without  any  conscious  effort  on  his  part,  his  bowels  established 
the  habit  of  moving  in  the  evenings  of  the  nights  he  remained  at  home,  and  in  the 
mornings  of  the  days  which  he  remained  there,  and  never,  except  under  unusual 
circumstances,  had  any  inclination  to  move  at  other  times. 

Many  instances  of  such  irregularity  and  prolonged  retention  of 
faeces  could  be  cited,  but  it  is  enough  to  state  that  the  length  of  time 
between  fascal  passages  is  so  variable  in  individuals  that  what  consti- 
tutes constipation  in  one  is  not  in  the  least  conclusive  of  such  a  condi- 
tion in  another. 

Those  extreme  instances  in  which  long  periods  of  time  elapse  be- 
tween the  stools  are  frequently  due  to  some  idiosyncrasy  or  deformity, 
and  they  can  only  be  considered  as  curiosities  in  this  connection. 
Mathews  (Diseases  of  the  Eectum,  p.  58)  reported  a  case  in  which  the 
fgecal  movements  occurred  at  first  once  in  two  weeks,  and  gradually 
extended  the  time  until  finally  the  patient's  bowels  moved  only  once 
in  four  months.  In  this  case  a  movement  of  the  girl's  bowels  was  not 
only  an  event  in  the  family  but  to  the  entire  neighborhood.  He 
states  that  there  was  no  impaction,  disease,  or  unnaturally  contracted 
condition  in  the  intestine,  that  no  odor  emanated  from  the  body,  and 
that  little  damage  resulted  to  the  general  health.  The  extreme  and 
alarming  reflex  symptoms  produced  in  this  case  by  the  introduction 
of  the  bougie  and  flooding  the  colon  with  water,  and  the  collapsed  and 
exhausted  condition  after  fsecal  passages,  clearly  indicated  some  irri- 
table or  obstructive  point  in  this  canal  which  would  account  in  a  large 
measure  for  the  girl's  constipation  in  the  first  place. 

The  author  had  a  patient  who  claimed  that  he  only  had  a  move- 
ment once  in  twenty-eight  days,  and  always  at  the  full  of  the  moon. 
These  instances,  however,  are  almost  insignificant  when  compared  with 
the  cases  reported  by  Strong  (Am.  J.  of  Med.  Scs.,  October,  1874,  p.  4-10), 
in  which  the  movements  occurred  once  in  eight  months  and  sixteen 
days;  Inman  (Half-Yearly  Abstract  in  Med.  Scs.,  vol.  xxi,  p.  275),  once 
in  two  years;  Valentine  (Bull,  de  scs.  med.,  t.  x,  p.  74),  once  in  nine 
months;  Devillier  (J.  de  med.,  1756,  t.  iv,  p.  257),  once  in  two  years; 
Chalmer  (Med.  Gaz.,  London,  1843,  vol.  xxi,  p.  20),  once  in  three  years, 
and  a  case  (Eecords  of  the  Phila.  Med.  Museum,  1805,  vol.  i,  p.  305) 


CONSTIPATION,  OBSTIPATION,  AND   F^CAL  IMPACTION        519 

where  the  patient  had  only  one  movement  in  fourteen  years.  Medical 
literature  is  full  of  such  eccentricities,  and,  strange  to  say,  these  individ- 
uals in  the  majority  of  cases  have  maintained  comparatively  good  health. 

The  only  explanation  of  such  facts  is  that  they  have  lived  upon  a 
diet  in  which  there  were  small  quantities  of  indigestible  substances, 
and  that  their  digestive  and  assimilative  functions  have  been  sufficiently 
active  to  appropriate  all  the  ingested  material,  with  the  exception  of 
a  very  minute  proportion. 

Leaving  out  of  account  these  phenomenal  cases,  and  coming  down 
to  the  every-day  individual  with  whom  the  physician  has  to  deal,  in 
order  to  determine  whether  a  patient  is  really  constipated  or  not,  one 
must  acquaint  himself  not  only  with  the  dietary  of  the  individual  but 
with  his  habits  from  childhood  in  regard  to  faecal  movements,  and  his 
occupation  and  practices  at  the  time  of  consultation. 

Constipation  is  not  a  disease  in  itself,  hut  a  symptom  or  manifestation 
of  functional  or  pathological  conditions.  It  is  produced  by  whatever 
conditions  retain  faecal  detritus  in  or  retard  its  passage  through  the 
intestinal  canal.  In  those  cases  in  which  the  fsecal  discharges  are  less 
than  normal  on  account  of  insufficient  or  improper  food,  the  patient 
usually  suffers  no  inconvenience  from  the  apparent  constipation;  under 
such  circumstances,  if  he  can  be  convinced  that  the  fsecal  passages  are 
entirely  adequate  in  proportion  to  the  amount  of  food  taken,  and  per- 
suaded not  to  indulge  in  laxative  or  cathartic  medicines,  the  greatest 
good  will  be  accomplished  for  him.  In  such  cases  as  suffer  from  oesoph- 
ageal stricture,  ulceration  of  the  stomach,  cirrhosis  of  the  liver,  stric- 
tures, cancers  or  tumors  of  the  pylorus,  stomach,  or  upper  end  of  the 
small  intestine,  all  of  which  prevent  the  ingestion  of  normal  quantities 
of  food  and  limit  that  which  is  taken  to  the  most  concentrated  forms, 
the  faecal  passages  will  not  only  be  very  small  in  quantity  but  ordinarily 
at  widely  separated  periods.  Such  cases  as  these  can  not  be  called  con- 
stipated, for  the  intestinal  functions  are  perfectly  normal,  in  that  they 
act  whenever  there  is  sufficient  material  for  them  to  act  upon. 

Defecation. — In  order  to  understand  constipation,  one  must  be 
familiar  with  the  processes  by  which  the  ingested  material  passes 
through  the  alimentary  canal,  and  the  conditions  necessary  to  establish 
normal  passages.  Practically  one  may  say  that  up  to  the  last  moment 
at  which  the  faecal  mass  is  extruded  from  the  body,  the  ingested  ma- 
terials are  carried  through  the  intestinal  tract  by  what  is  known  as 
peristaltic  action.  The  food  is  received  into  the  stomach  and  the  albu- 
menoids  are  subjected  to  the  action  of  the  gastric  secretions,  thus  being 
converted  into  peptones;  after  this  it  is  passed  through  the  pylorus 
into  the  other  sections  of  the  intestine. 

The  reaction  of  the  contents  of  the  stomach  as  they  pass  little  by 


520        THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

little  through  the  pylorus  is  acid;  the  secretions  of  the  small  intestine, 
the  bile,  and  the  pancreatic  fluid  are  all  alkaline;  thus,  when  the  acid 
contents  of  the  stomach  are  poured  into  the  small  intestine,  the}'  pro- 
duce a  stimulation  or  irritation  which  causes  a  wave  of  muscular  con- 
traction constituting  peristaltic  action.  At  the  same  time  the  chemical 
reaction  of  this  acid  substance  upon  the  alkaline  contents  of  the  intes- 
tine creates  certain  gases  which  serve  to  distend  the  caliber  of  the  gut, 
stimulate  still  further  the  muscular  contractions,  and  thus  facilitate 
the  passage  of  the  semifluid  substances  through  the  tract. 

These  gases  consist  largely  of  carbonic-acid  gas,  nitrogen,  carbureted 
hydrogen,  hydrogen,  and  sulphureted  hydrogen  (Planer,  Sitzungsbe- 
richte  d.  Akadem.  d.  ^Yissenschaften  zu  Wien,  vol.  xlii;  S.  J.  Charles, 
British  Med.  Jour.,  February,  1885).  The  presence  of  these  gases, 
therefore,  is  not  abnormal  or  detrimental,  but,  on  the  contrary,  most 
useful.  It  is  only  when  they  are  found  in  improper  proportions  and 
are  more  irritating  than  normal  that  they  are  unhealthy,  in  that  they 
produce  too  rapid  and  severe  peristalsis  and  too  great  distention  of 
the  intestinal  canal,  thus  causing  atony  or  paralysis  of  the  circular 
fibers  and  consequent  inability  to  contract. 

Ordinarily  the  gases  are  reabsorbed  by  the  blood-vessels  or  discharged 
with  the  faecal  mass  through  the  anus.  If,  however,  there  is  an}'  inter- 
ference with  such  absorption  or  passages,  either  through  catarrhal  in- 
flammation and  consequent  mucous  coating  of  the  intestinal  canal  or 
through  obstruction  due  to  volvulus,  acute  angulation  or  stricture,  the 
gases  will  accumulate  and  cause  overdistention,  or  pass  backward  along- 
side of  the  faecal  materials  in  the  intestinal  canal  and  into  the  stomach, 
being  discharged  in  this  direction.  Other  sources  of  stimulation,  aside 
from  acid  peptones  and  the  production  of  gases,  are  the  harsh,  undi- 
gested particles  of  food  which  were  not  acted  upon  by  the  gastric  secre- 
tions. These  also  stimulate  the  muscular  contractions  of  the  small 
intestine. 

In  addition  to  these  intra-intestinal  stimulants  to  peristaltic  action, 
there  is  another  which  is  of  great  importance,  and  is  generally  disre- 
garded in  the  discussion  of  this  subject;  it  is  the  to-and-fro  movement 
imparted  to  the  intestine  by  the  processes  of  respiration.  The  up-and- 
down  movement  of  the  diaphragm  during  every  inspiration  and  expira- 
tion imparts  to  the  small  intestine  in  particular,  arid  to  the  transverse 
colon,  a  movement  which  accomplishes  a  churning,  as  it  were,  of  the 
intestinal  contents,  changes  the  position  of  the  guts,  and  thus  con- 
tributes to  the  movement  of  the  substances  along  the  alimentary  canal. 
The  importance  of  this  stimulus  can  not  be  overestimated,  for  its  im- 
pairment, either  by  lack  of  exercise,  improper  clothing — such  as  tight 
corsets — or  disease,  soon  exhibits  itself  in  inactivity  of  the  intestinal 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL   DIPACTION        521 

functions^  and  the  development  of  constiiDation  or  other  intestinal 
derangements. 

Overstimulation  of  the  intestinal  mucous  membrane  by  too  large 
quantities  of  acrid  food,  or  by  too  much  coarse,  indigestible  fiber,  is  likely 
to  result  in  decreased  sensitiveness  of  the  nerve-ends,  and  consequent 
inactivity  of  the  muscular  contractions.  "^Tiile  a  certain  amount  of 
these  substances  is  desirable  in  one's  dietary,  an  excess  of  them  may 
result  in  the  very  condition  which  they  are  intended  to  obviate. 

The  peristaltic  action  of  the  small  intestine  is  accomplished  largely 
by  the  circular  muscular  fibers.  There  are  some  very  fine  longitudinal 
fibers  in  this  portion  of  the  intestine,  but  their  action  is  doubtful.  As 
the  fffical  material  here  is  almost  always  fluid  or  semifluid  there  is  little 
necessity  for  longitudinal  fibers  to  draw  the  intestine  up  over  the  mass 
which  is  squeezed  down  by  contraction  of  the  circular  fibers. 

The  processes  of  digestion  are  practically  completed  in  the  small 
intestine,  and  the  absorption  of  chyle  takes  place  at  the  same  time 
through  the  villi.  By  the  time  the  food  reaches  the  c^cum,  therefore, 
a  large  proportion  of  its  nutritive  elements  are  absorbed.  Its  fluid 
character,  however,  is  not  very  greatly  diminished,  and  on  this  account 
it  is  easily  pushed  through  the  cscal  or  Bauhinian  valve  into  the  ascend- 
ing colon.  As  this  portion  of  the  large  intestine  runs  directly  upward, 
the  faecal  material  must  therefore  travel  directly  against  the  force  of 
gravity,  consequently  its  hitherto  rapid  movement  is  checked,  and  it 
rests  in  this  position  for  a  considerable  time.  As  a  consequence  of  this, 
absorption  of  the  fluids  takes  place  largely  at  this  point,  and  by  the  time 
the  fffical  matter  reaches  the  upper  portion  of  the  ascending  colon  it 
becomes  quite  consistent.  On  this  account  it  requires  the  mechanism 
of  the  fully  developed  longitudinal  muscular  fibers  to  pull  the  intestinal 
wall  upward  (with  regard  to  the  course  of  the  intestine)  over  the  mass 
after  it  has  been  squeezed  forward  by  the  circular  fibers.  In  conse- 
quence of  this  hardening  or  solidification  of  the  ffecal  material  com- 
posed largely  of  the  fibrous  and  indigestible  portions  of  the  food,  the 
mucous  membrane  of  the  colon  is  constantly  more  or  less  irritated  by 
it,  and  becomes  thickened  and  less  sensitive  than  that  of  the  small 
intestine. 

These  facts  are  of  considerable  importance  when  one  considers  the 
subject  of  artificial  anus  on  the  right  side.  The  further  the  opening  in 
the  colon  is  made  from  the  csecal  valve  the  more  solid  will  be  the  fasces, 
and  therefore  less  inconvenience  will  result  from  their  constant  escape 
through  it. 

Where  there  is  too  much  fibrous  or  indigestible  material  taken  for 
considerable  periods  of  time,  and  it  accumulates  in  the  colon,  the  mucous 
menibrane  may  become  so  insensitive  that  the  gases  and  rough  materials 


522  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

fail  to  stimulate  peristalsis;  consequently  the  patient  will  develop  a 
tardy  movement  of  the  fecal  mass  and  undue  distention  of  the  intes- 
tine, which  resolves  itself  into  atony  of  the  muscles,  chronic  constipa- 
tion, and  sometimes  impaction. 

The  glands  in  the  large  intestine  are  not  only  absorptive  but  secret- 
ing glands,  being  possessed  of  a  large  number  of  goblet  or  mucus-pro- 
ducing cells.  When  the  intestine  has  been  overstimulated  and  irritated 
by  the  prolonged  presence  of  hard  faecal  material,  an  excess  of  mucus 
is  secreted,  and  we  have  developed  what  is  known  as  mucous  colitis 
or  hypertrophic  catarrh. 

After  the  faecal  mass  has  been  carried  through  the  ascending  colon 
around  the  hepatic  flexure  into  the  transverse  colon,  if  this  latter  por- 
tion is  in  its  normal  position  it  travels  through  a  horizontal  tract  in 
which  the  movement  is  more  rapid  and  less  difficult.  Here  it  is  sub- 
jected to  the  action  of  the  abdominal  muscles  and  the  diaphragm.  If, 
however,  the  transverse  colon  be  displaced,  as  it  frequently  is  in  en- 
teroptosis,  sagging  downward  in  the  abdominal  cavity  below  the  umbili- 
cus and  even  to  the  pubis,  the  faecal  mass  will  be  arrested  or  retarded 
in  this  portion  of  the  tract. 

When  the  mass  has  once  been  emptied  into  the  descending  colon, 
it  passes  downward  to  the  sigmoid  flexure  by  the  force  of  gravity  and 
peristaltic  action  of  the  gut.  Unless  there  is  some  coarctation  of  or 
pressure  upon  the  intestine,  it  passes  through  this  section  rapidly 
enough. 

The  sigmoid  flexure  when  empty  lies  chiefly  in  the  pelvic  cavity, 
its  loops  running  horizontally  downward,  upward,  and  downward  again 
to  Join  the  rectum.  Xext  to  the  csecum  this  is  the  most  distensible 
portion  of  the  large  intestine,  and  is  the  typical  reservoir  for  the  storage 
of  fgecal  material.  ^Tien  empty  or  partially  filled,  this  portion  of  the 
large  intestine  forms  an  acute  angle  with  the  rectum,  which  practically 
closes  the  communication  between  these  two  organs.  Besides  this,  at 
the  junction  of  the  two  there  is  an  aggregation  of  circular  fibers  upon 
one  side  which  act  as  a  sort  of  valve  to  prevent  the  escape  of  the  fcPcal 
mass  into  the  rectimi  so  long  as  the  acute  flexure  exists.  Wlien,  how- 
ever, the  sigmoid  becomes  distended  with  faecal  matter  or  gases,  it  rises 
upward  into  the  abdominal  cavity,  straightens  out  the  flexure  at  the 
junction  between  it  and  the  rectum,  thus  opening  up  the  passage  be- 
tween the  two  organs  and  facilitating  the  escape  of  the  faecal  material 
downward.  If  from  any  cause,  such  as  inflammator}'  adhesion,  adhesive 
bands,  tumors,  or  other  conditions,  the  sigmoid  is  prevented  from  rising 
up  into  the  abdominal  cavity,  the  faecal  mass  will  then  have  to  be  lifted 
directly  upward  and  forced  past  the  contracted  orifice  connecting  it 
with  the  rectum  in  order  that  a  movement  of  the  bowels  mav  take 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        523 


place  (Fig.  177).    Such  conditions  are  among  the  most  frequent  causes 
of  constipation. 

After  the  fgecal  mass  has  been  passed  into  the  rectum  from  the  sig- 
moid, it  is  carried  downward  by  the  force  of  the  rectal  muscles.  It 
does  not  drop  into  a  vacant  cavity,  as  is  sometimes  described,  but  is 
directed  by  the  folds  of  Houston  in  a  rotary  course  from  one  side 
of  the  intestine  to  the  other  until  it  reaches  the  anal  canal,  which  is 
normally  closed  by  the  sphincter  muscles.  When  the  faecal  mass  reaches 
this  lower  portion  of  the  rectum,  aromid  which  are  distributed  the 
sensitive  nerves,  the  inclination  to  go  to  stool  becomes  imperative.  If 
the  place  and  season  are  appropriate,  and  there  is  no  local  condition  at 
the  anus  preventing  the  same, 
a  fgecal  passage  occurs,  but  it 
can  generally  be  restrained  by 
voluntary  contraction  of  the 
sphincter. 

Reverse  Peristalsis. — It  was 
stated  by  O'Beirne  that  when 
the  faecal  mass  has  been  passed 
into  the  rectum  and  is  not  im- 
mediately expelled,  a  reverse 
peristalsis  takes  place  which 
carries  it  upward  into  the  sig- 
moid again;  also  that  the  rec- 
tum, except  in  its  lower  dilated 
portion,  is  always  empty  of 
fgeces.  These  statements  have 
been  accepted  by  the  large  ma- 
jority of  writers  upon  this  sub- 
ject; but,  after  carefully  study- 
ing it,  and  examining  many 
cases  with  regard  to  these  facts, 
it  is  not  possible  to  verify  them.  In  9  out  of  10  cases  examined  at  any 
period  from  two  to  three  hours  after  a  movement,  one  will  find  a  greater 
or  less  quantity  of  faecal  material  in  the  lower  portion  of  the  rectum. 
If  pledgets  of  cotton,  plain,  coated  with  vaseline  or  soaked  with  water, 
are  introduced  into  the  rectum  and  left  there  for  two,  three,  six,  or 
twenty-four  hours,  during  which  time  the  patient  has  no  movement 
of  the  bowels,  at  the  end  of  the  time  the  pledgets  will  be  found  in  the 
ampulla  of  the  rectum  just  where  they  were  left.  When  the  rectum 
has  been  thoroughly  filled  with  fscal  material  and  there  is  an  obstruc- 
tion at  the  anal  outlet,  it  is  possible  that  muscular  straining  and  con- 
traction of  the  rectal  walls  may  force  the  mass  upward  instead  of  down- 


FlG.  177. — DiAGEAMMATIC  ILLUSTRATION  OF  AcUTE 

Flexure  between  the  Sigmoid  and  Rectum. 


524  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

ward,  because  this  is  in  the  line  of  least  resistance;  there  may  also  be 
an  apparent  peristaltic  action  upon  fluid  materials  and  gases  in  cases 
where  there  is  a  tight  sphincter  and  voluntary  resistance  to  the  passage 
downward.  In  such  cases  there  is  no  absolute  closure  of  the  intestine 
above,  but  simply  a  circular  contraction  of  the  canal  which  decreases 
the  caliber  and  capacity  of  the  gut  as  it  proceeds  downward  toward  the 
rectum  in  a  wave-like  manner;  when  the  wave  reaches  this  organ  and 
decreases  its  capacity,  the  contents  are  forced  to  move  in  some  direction, 
and  they  escape  upward  into  that  portion  of  the  intestine  which  has 
become  relaxed  by  the  passage  of  the  peristaltic  wave  beyond  it;  thus, 
wave  after  wave  acting  in  a  similar  manner,  the  contents  are  carried 
upward  through  a  certain  portion  of  the  alimentary  tract. 

The  author  has  examined  the  peristaltic  action  in  a  large  number 
of  cases  in  which  the  abdomen  was  opened,  and  he  has  never  yet  seen 
any  reverse  wave;  fluid  injected  into  the  rectum  while  the  sigmoid  flexure 
was  exposed  has  not  been  carried  up  by  any  such  motion.  Moreover,  if 
there  were  such  a  reverse  peristaltic  action,  it  appears  that  it  would 
manifest  itself  in  those  cases  in  which  an  artificial  anus  is  mado  for 
tight  strictures  of  the  rectum,  and  in  which  accumulated  faecal  masses 
are  left  below  the  artificial  opening.  Within  the  past  year  this  latter 
condition  was  observed  no  less  than  four  times,  and  in  each  case  it 
was  necessary  to  remove  the  facal  masses  from  the  distal  portion  of 
the  sigmoid  by  mechanical  means.  There  has  never  been  the  least 
tendency  toward  retroperistaltic  action  to  relieve  this  accumulation;  it 
seems,  therefore,  when  the  faecal  mass  has  once  passed  into  the  rectum, 
it  remains  there  until  it  is  removed  by  natural  or  artificial  means,  and 
the  longer  it  remains  there  the  drier  and  harder  will  it  become  on 
account  of  the  gradual  absorption  of  its  fluid  constituents  by  the  glands 
of  the  organ. 

The  process  of  defecation  may  therefore  be  briefly  described  as  con- 
sisting first  in  peristaltic  action  of  the  entire  intestinal  tract,  which 
eventually  brings  the  faecal  material  down  and  stores  it  in  the  sigmoid 
flexure;  as  this  organ  gradually  distends  it  rises  upward  out  of  the 
pelvic  cavity,  unfolding  its  convolutions  and  the  flexure  between  it  and 
the  rectum,  thus  opening  up  to  a  greater  or  less  degree  this  narrowed 
aperture.  When  the  sigmoid  has  been  straightened  out  sufficiently  to 
bring  its  last  loop  in  a  more  or  less  straight  line  with  the  upper  seg- 
ment of  the  rectum,  the  gas  and  faecal  material  pass  into  the  latter 
and  are  carried  downward  as  before  described  until  they  reach  the  lower 
end  or  sensitive  area  of  this  organ;  at  this  point  the  stimulation  of 
the  cerebro-spinal  nerves  causes  a  closer  contraction  of  the  external 
sphincter  muscle,  and  the  mass  is  arrested  until  the  mental  action  of 
the  individual  brings  into  play  the  inhibitory  power  over  this  muscle, 


CONSTIPATION,  OBSTIPATION,  AND   F^CAL   IMPACTION        525 

causing  it  to  relax  and  thus  admit  of  a  fascal  movement.  Under  cer- 
tain circumstances,  however,  the  peristaltic  force  is  so  great  that  it 
overcomes  the  resistance  of  the  external  sphincter  and  involuntary 
movements  occur. 

At  the  moment  of  stool,  if  the  mass  is  at  all  hard,  the  assistance 
of  the  abdominal  muscles  and  the  diaphragm  are  brought  into  play 
through  the  process  called  "  straining."  This  straining  compresses  the 
small  intestines,  the  sigmoid  flexure,  the  bladder,  and  through  these 
organs  the  rectum;  owing  to  the  protected  position  of  the  ascending 
and  descending  colon,  it  has  little  influence  upon  these  portions  of  the 
intestinal  tract. 

Remission  of  Inclination  to  Defecate. — When  the  inclination  to  have 
a  passage  is  resisted,  the  desire  often  passes  over,  and  may  not  occur 
again  until  the  next  regular  period  for  such  a  movement.  This  remis- 
sion of  desire  lends  a  plausibility  to  the  theory  of  O'Beirne,  but  the 
mass  is  never  lifted  back  into  the  sigmoid.  It  simply  adjusts  itself 
to  the  rectal  ampulla,  and  the  parts  become  tolerant  of  its  presence. 
If  the  rectum  is  inflamed  or  the  fgeces  fluid,  this  tolerance  will  not  be 
manifested. 

From  this  description  of  the  functional  action  of  defecation,  one 
may  infer  that  whatever  interferes  with  the  passage  of  the  fgecal  mass 
through  the  intestinal  canal  will  develop  constipation.  On  the  other 
hand,  whatever  exaggerates  these  functional  actions,  hastens  the  ingesta 
through  the  intestinal  tract,  increases  the  amount  of  the  fluid  secre- 
tion therein,  or  unduly  stimulates  the  peristaltic  action,  will  bring  on 
"  diarrhoea." 

At  the  heading  of  this  chapter  the  terms  constipation,  obstipation, 
and  impaction  have  been  used;  the  distinction  between  these  different 
terms  must  be  borne  clearly  in  mind. 

By  constipation  is  understood  a  condition  of  insufficient  and  tardy 
fgecal  passages  due  to  functional  conditions  or  diseases  of  the  intes- 
tinal tract. 

Obstipation  refers  to  those  conditions  in  which  there  is  a  sufficient 
quantity  of  faecal  material  and  adequate  functional  activity,  but  in  which 
there  exists  some  deformity,  growth,  or  contracture  in  the  intestinal 
tract  that  causes  mechanical  obstruction  to  the  passages. 

By  impaction  is  understood  an  accumulation  of  fscal  material,  usu- 
ally hard,  dry,  and  stuck  together  in  a  mass,  which  is  arrested  at  some 
point  through  an  organic  or  spasmodic  narrowing  of  the  intestinal 
canal. 

The  symptoms  of  constipation  and  obstipation  so  overreach  one 
another  that  it  is  almost  impossible  to  clearly  separate  them  without 
much  repetition,  therefore  we  will  describe  them  together. 


626  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

Etiology. — The  causes  of  these  conditions  may  be  defined  as  func- 
tional and  mechanical,  predisposing  and  exciting;  those  cases  due  to 
functional  derangement  are  true  constipation,  while  those  due  to  me- 
chanical obstruction  are  obstipation. 

Predisposing  Causes. — Heredity. — The  influence  of  heredity  in  con- 
stipation is  very  marked;  the  condition  may  occur  in  all  the  members 
of  a  family,  and  frequently  it  occurs  in  three  and  sometimes  in  four 
generations. 

Predisposition  to  catarrhal  conditions,  the  habits  of  life,  carelessness 
in  attention  to  the  activity  of  the  bowels,  the  continuous  use  of  laxa- 
tives and  their  administration  to  children,  account  in  a  large  measure 
for  this  apparent  heredity.  Nevertheless  there  are  a  certain  number 
of  cases  in  which  the  father  and  mother  are  constipated,  and  their 
children  inherit  this  tendency,  notwithstanding  the  most  careful  hygi- 
enic regulations  and  abstinence  from  the  administration  of  laxatives. 
In  such  cases,  the  children  are  born  with  deficient  intestinal  secretions 
and  peristaltic  action.  There  is  generally  in  these  cases  frequent  urina- 
tion, which  accounts  in  a  measure  for  the  dryness  of  the  fgecal  mass  and 
the  difficulty  in  its  movement  along  the  intestinal  tract. 

Age. — Age  has  considerable  influence  in  the  production  of  constipa- 
tion. Old  people,  owing  to  deficient  exercise,  relaxed  muscular  con- 
ditions, and  decreased  peristaltic  action,  together  with  insufficient  intes- 
tinal secretions  which  render  the  faecal  mass  dry,  are  ordinarily  the 
victims  of  this  disorder.  The  functions  of  the  animal  economy  at  this 
period  of  life  are  less  active,  the  appetite  less  voracious,  and  conse- 
quently the  fjecal  passages  adequate  to  maintain  good  health  are  not 
necessarily  so  abundant  or  so  frequent  as  in  earlier  life. 

Old  people  are  seen  frequently  whose  bowels  move  once  in  three 
or  four  daj's  without  any  artificial  stimulation,  and  who  are  in  perfect 
health,  with  the  exception  that  they  suffer  from  a  mild  degree  of  haemor- 
rhoids.    Such  can  not  properly  be  called  constipated. 

Very  young  children  are  more  subject  to  constipation  than  those 
aged  two  years  and  upward.  This  is  due  occasionally  to  malformations, 
such  as  narrowing  of  the  intestinal  tract  at  some  point.  It  is  often 
caused  by  artificial  feeding,  or  by  a  deficient  quantity  of  lactose  in 
the  mother's  milk.  The  concentrated,  uniform  diet  of  milk  unless  freely 
supplied  with  this  laxative  tends  toward  costiveness,  whether  in  the 
adult  or  in  the  child.  Lack  of  exercise  and  deficient  oxygenation  will 
also  account  in  a  measure  for  the  condition  in  young  children.  The 
fact  remains,  however,  and  is  inexplicable,  except  upon  the  ground  of 
heredity,  that  a  large  number  of  children  born  under  similar  circum- 
stances, fed  in  a  similar  manner,  with  equal  hygienic  care  and  identical 
environments,  differ  materially  in  the  functional  action  of  their  bowels. 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        527 

Some  exhibit  symptoms  of  constipation  from  their  very  birth  without 
any  anatomic  conformation  to  account  for  the  same,  while  others  pass 
through  infancy  with  perfectly  normal  physiological  actions.  In  chil- 
dren from  three  to  twelve  years  of  age  constipation  is  rather  a  rare 
disease;  the  period  of  puberty  or  adolescence^,  from  twelve  to  twenty 
years  of  age,  however,  is  frequently  the  time  when  this  habit  is  devel- 
oped. Especially  is  this  true  in  the  higher  walks  of  life,  where  false 
modesty  or  prudery  with  regard  to  the  natural  functions  causes  young 
women  and  young  men  to  neglect  the  calls  of  Nature,  or  rather  to  refvise 
to  honor  them  lest  they  excite  some  thoughts  not  altogether  refined 
in  the  minds  of  persons  present.  This  mock  modesty  and  the  absorp- 
tion in  school,  society,  and  domestic  affairs  bring  on  the  worst  types 
of  constipation. 

The  normal  stimulation  of  the  intestinal  mucous  membrane  and  the 
inclination  to  go  to  stool  may  be  resisted  so  persistently  that  the  nerve- 
ends  become  insensitive  to  impressions,  and  the  faecal  masses  may  lie 
day  after  day  and  week  after  week  in  the  rectum,  sigmoid  flexure,  and 
other  portions  of  the  colon  without  any  unusual  desire  for  defecation. 

A  young  woman,  who  went  upon  a  sailing  cruise  for  eight  weeks, 
had  only  three  movements  of  her  bowels  during  the  entire  time  simply 
because  she  was  afraid  that  some  gentleman  would  see  her  going  toward 
the  toilet.  The  result  was  a  severe  proctitis  and  a  constipated  condition 
which  required  a  long  time  and  much  treatment  to  relieve.  In  such 
cases  it  is  habit  and  not  age  that  produces  the  constipation.  In  people 
of  middle  age  it  is  ordinarily  the  result  of  neglect,  improper  diet,  or 
organic  disease. 

Sex. — False  modesty  in  young  women,  the  lack  of  outdoor  exercise, 
neglect  of  regularity,  and  after  puberty  the  physiological  phenomena 
in  a  woman's  life,  tend  toward  producing  constipation.  Congestion  of 
the  ovaries,  and  more  or  less  enlargement  of  the  uterus  at  every  men- 
strual period,  the  processes  of  pregnancy,  resulting  in  prolonged  pres- 
sure upon  the  rectum  and  pelvic  colon  by  the  gravid  uterus,  a  gen- 
eral relaxation  of  the  abdominal  muscles,  and  the  lack  of  support  to 
the  intestines  after  childbirth,  together  with  frequent  displacement  or 
disease  of  these  generative  organs,  render  the  female  sex  much  more 
subject  to  constipation  than  the  male. 

Occupation. — Occupation  is  another  predisposing  cause.  A  seden- 
tary life,  such  as  that  of  professional  men,  bookkeepers,  office  clerks, 
seamstresses,  etc.,  predisposes  to  the  development  of  this  condition. 
Such  individuals,  unless  they  are  systematic  in  the  habit  of  going  to 
stool  at  regular  hours  and  allowing  nothing  to  interfere  with  this  func- 
tion, are  very  likely  to  develop  the  chronic  form.  As  Johnston  says: 
"  Intellectual  work,  not  only  from  the  muscular  inactivity  which  it 


528  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

entails,  but  from  the  diversion  of  energy  to  the  nerve-centers,  develops 
the  constipated  habit  as  well  as  indigestion." 

Painters,  workers  in  lead  and  other  metals  are  predisposed  to  it. 
Sailors,  railroad  men,  and  others  whose  occupations  prevent  regular 
attention  to  these  functions  are  subject  to  constipation;  the  large  ma- 
jority of  them  are  habitual  users  of  cathartics,  the  omission  of  which 
results  in  acute  attacks  and  sometimes  in  serious  results.  Here  again 
it  is  not  the  occupation  so  much  as  the  habits  which  it  entails. 

The  Exciting  Causes. — Food. — The  normal  action  of  the  bowels  de- 
pends upon  the  character  and  quantity  of  the  food  taken. 

Quality. — Highly  concentrated  foods  produce  little  fgecal  material. 
A  vegetable  or  mixed  diet  gives  rise  to  a  larger  quantity  of  faecal  dis- 
charge than  does  an  animal  diet,  at  the  same  time  the  stools  are  ordi- 
narily less  firm;  this  is  owing  to  the  fact  that  vegetables  contain  a 
larger  proportion  of  water  and  fibrous  material.  Within  normal  limita- 
tions, therefore,  a  vegetable  diet  is  less  likely  to  be  the  cause  of  con- 
stipation than  is  a  nitrogenous  one.  On  the  one  hand,  vegetables  taken 
in  excess  produce  excessive  stools,  and  the  accumulation  of  fibrous  ma- 
terial in  the  large  intestine  is  likely  to  bring  on  an  insensitive  condition 
of  the  mucous  membrane,  and  hence  a  tardy  action  which  results  eventu- 
ally in  chronic  constipation;  on  the  other,  a  purely  nitrogenous  diet 
furnishes  a  very  small  quantity  of  refuse  material,  and  consequently 
small  faecal  discharges  which  result  in  irregular  or  infrequent  stools. 

Quantity. — The  amount  of  food  taken  is  also  an  element  in  the  pro- 
duction of  constipation.  Cases  suffering,  as  has  already  been  said,  from 
intestinal,  oesophageal,  and  stomachic  conditions  which  limit  the  quan- 
tity of  food  taken  and  necessitate  its  being  of  the  most  concentrated 
varieties,  will  pass  very  small  amounts  of  faecal  material;  such  cases, 
however,  can  not  be  considered  as  constipated.  On  the  other  hand, 
patients  may  take  too  much  food.  People  of  sedentary  habits,  who  live 
in  luxury  and  are  fond  of  gastric  indulgences,  frequently  develoj^  the 
habit  of  eating  large  quantities,  more  than  their  organs  can  digest  or 
assimilate,  and  the  result  is  that  they  either  have  enormous  passages 
or  there  is  an  accumulation  of  such  materials  in  the  colon  with  over- 
distention,  atony,  and  chronic  constipation.  In  such  individuals  the 
limitation  of  the  amount  of  food  is  frequently  the  most  successful  treat- 
ment. The  small  amount  of  fluids  taken  is  also  frequently  a  cause. 
It  has  been  determined  by  physiologists  that  the  average  composition 
of  the  faecal  mass  is,  approximately,  water  75  per  cent,  solid  material 
25  per  cent.  Whenever  the  liquid  constituents  fall  below  50  per  cent 
the  faecal  movements  are  retarded  and  difficult,  and  when  they  reach 
as  low  as  20  per  cent  (Illoway,  Constipation,  p.  39)  the  movement  is  prac- 
tically impossible. 


COXSTIPATIOX,  OBSTIPATION,  AND   F.ECAL   DIPACTIOX        529 

The  dnTiess  of  the  fEecal  material  is  brought  about  also  b}'  numerous 
functional  or  pathological  processes.  Diabetes,  nursing,  excessive 
diuresis,  or  perspiration  reduces  the  fluidity  of  the  intestinal  contents, 
and  hence  contributes  to  the  production  of  constipation.  This  is  also 
noticed  in  cases  of  malarial  fever,  the  night-sweats  of  phthisis,  and 
as  a  result  of  very  hot  weather  in  a  great  many  cases. 

Good  and  Everly  (Braithwaite's  Eetrospect,  vol.  xvii,  p.  152)  ascribe 
constipation  to  an  excessive  absorption  of  the  fluids  in  the  small  intes- 
tine. Johnston  also  states  (Pepper's  System  of  Medicine,  vol.  ii,  p.  643) 
that  constipation  may  be  caused  by  exercises  which  produce  excessive 
perspiration,  and  by  stimulating  the  functions  in  general  cause  the  too 
rapid  absorption  of  fluids  in  the  intestinal  canal. 

The  necessity,  therefore,  of  consuming  a  sufficient  quantity  of  water 
to  keep  the  faecal  passages  soft  can  well  be  understood.  As  to  whether 
this  water  should  be  taken  before  meals,  with  the  food,  or  afterward, 
is  a  question  to  be  decided  by  the  condition  of  the  patient's  stomachic 
digestion.  Wliere  there  is  a  catarrh  of  the  stomach  and  an  accumula- 
tion of  mucus  in  this  organ  large  drafts  of  water  before  meals,  in 
order  to  wash  out  this  material  and  cleanse  the  walls  of  the  organ,  are 
desirable.  TThen  there  is  feebleness  or  inadequacy  of  the  digestive 
agents  in  the  stomach  the  patient  should  avoid  taking  fluids  along 
with  his  food,  but  under  other  circumstances,  such  as  are  found  in 
cases  with  excessive  gastric  secretions,  a  certain  amount  of  water  taken 
at  this  time  will  have  a  beneficial  effect.  In  the  class  of  cases  in  Avhich 
water  is  contraindicated  during  meals,  it  should  be  freely  indulged  in 
two  or  three  hours  afterward. 

Chemical  Causes. — The  chemical  reaction  of  the  intestinal  contents 
is  normally  acid  in  a  carbohydrate  diet,  alkaline  in  a  nitrogenous  diet, 
and  neutral  in  a  mixed  diet.  Thus  it  is  that  patients  who  are  in  the 
habit  of  living  upon  a  mixed  diet,  if  they  suddenly  change  to  a  fresh 
vegetable  and  fruit  diet,  develop  a  diarrhoea  owing  to  the  excessive  and 
unusual  acidity  of  the  contents  of  the  large  intestine.  On  the  other  hand 
vegetarians,  if  they  change  their  mode  of  life  and  begin  to  live  upon  meat 
and  nitrogenous  materials,  are  likely  to  become  constipated.  >Speaking 
in  a  general  way,  therefore,  the  proper  and  normal  regulation  of  intes- 
tinal action  demands  a  mixed  diet,  together  with  a  sufficient  quantity 
of  water  to  maintain  the  soft  or  semifluid  condition  of  the  stools. 

Drugs  and  Medicines. — In  the  same  line  with  foods  may  be  classed 
certain  vegetable  and  mineral  substances,  which  being  taken  into  the 
intestinal  tract  bring  about  delayed  or  insuflicient  stools.  An  excessive 
quantity  of  lime  salts,  lead,  opium,  tannic  acid,  alum,  etc.,  all  produce 
this,  either  by  their  action  upon  the  mucous  membrane  or  upon  the 
nervous  system. 
34 


632  THE   ANUS,   RECTUM,   AND   PELVIC  COLON 

As  a  matter  of  fact,  however,  iii  all  of  these  patients  the  change  of 
environment,  habits,  and  dietary  at  the  time,  or  after  the  beginning 
of  tht'ir  nervous  symptoms,  might  account  in  a  degree  for  their  con- 
stipation. These  facts,  however,  do  not  explain  the  occurrence  of  con- 
stipation in  almost  every  case  of  ataxia,  and  in  individuals  with  whom 
there  has  been  no  change  of  circumstances,  environments,  or  dietary. 
Whether  the  sympathetic  ganglia  and  the  plexus  of  Auerbach  and  Meiss- 
ner  take  part  in  the  sclerotic  process  or  not,  or  whether  it  is  simply 
an  involvement  of  the  cerebro-spinal  nerve-roots  and  centers  which 
control  the  inhibition  of  the  circular  muscular  fibers,  is  not  known;  but 
constipation  is  nearly  always  aii  accompaniment  of  the  disease,  and  all 
remedies  directed  toward  it  are  of  only  temporary  benefit  unless  there 
is  concomitant  improvement  in  the  nervous  condition. 

Under  this  heading  one  may  group  that  type  of  constipation  termed 
spastic,  and  due,  according  to  Rosenheim  (Pathol,  u.  Therap.  der 
Krankh.  des  Darmes,  1893),  Kaczorowski  (Deutsche  med.  Wochen- 
schrift,  1888,  No.  1),  and  Illoway  {op.  cif.,  p.  88),  to  enterospasm. 

It  is  due  to  partial  or  general  tonic  contraction  of  the  muscles  of 
the  intestine,  the  circular  and  longitudinal  fibers  contracting  syn- 
chronously and  persistently,  and  thus  preventing  any  movement  of  the 
fiecal  mass. 

It  is  said  to  be  frequent  in  basilar  meningitis  and  pathological  pro- 
cesses that  produce  pressure  upon  the  pons  or  medulla  oblongata,  and  in 
lead-poisoning. 

The  partial  type  of  enterospasm  is  frequent  in  acute  gastritis  and 
intestinal  indigestion,  and,  according  to  Rosenthal,  may  be  produced 
by  chronic  gastric  catarrh.  The  same  author  speaks  of  this  condition 
as  "  crises  enteriques  "  occurring  in  the  course  of  tabes  dorsalis.  The 
constipation  in  this  type  of  cases,  as  can  be  readily  understood,  is  a 
matter  of  no  importance  compared  with  the  general  condition  which  pro- 
duces it.  It  increases  or  decreases,  following  the  course  of  the  disease 
of  which  it  is  a  symptom,  and  needs  no  therapy  of  its  own.  Entero- 
spasm occurs  during  the  course  of  neurasthenia,  hysteria,  and  acute 
nervous  excitement.  In  such  instances  the  management  of  the  neurosis 
is  the  part  of  the  physician;  the  constipation  will  take  care  of  itself. 

Illoway  states  that  partial  enterospasm  may  be  associated  with  atony 
of  the  intestinal  muscles,  which  opinion  seems  to  be  corroborated  by 
Reynolds's  System  of  Medicine,  Rosenheim  (op.  cit.),  Fleiner  (Berliner 
klin.  Wochenschrift,  January,  1893),  and  Cherchewski  (Revue  de  med., 
October  and  December,  1883).  He  includes  spasmodic  stricture  of  the 
rectum  and  contraction  of  the  sphincter  ani  as  types  of  enterospasm. 
These  conditions,  however,  being  due  in  the  large  majority  of  cases  to 
local  causes,  can  not  be  properly  included  in  this  category. 


CONSTIPATION,  OBSTIPATION,  AND   F^CAL  IMPACTION        533 

Local  and  Mechanical  Causes. — There  are  causes  which  act  in  a 
mechanical  manner  by  offering  an  obstruction  at  some  point  or  other 
of  the  intestinal  tract  to  the  passage  of  the  ftecal  mass.  The  constipa- 
tion produced  by  these  has  been  termed  obstipation.  The  impression 
has  gone  abroad  in  certain  sections  that  this  term  is  applied  only  to 
those  obstructions  found  in  the  rectum,  particularly  those  produced  by 
inflammation,  hj-pertrophy,  or  malformation  of  Houston's  valves.  Such 
is  not  the  case.  Ohstipation  consists  in  a  mechanical  obstruction  to  the 
passage  of  faecal  matter  at  any  portion  of  the  intestinal  canal. 

In  children  it  is  frequently  due  to  the  imperfect  absorption  of  the 
SEeptum  dividing  the  rectum  and  the  anus  in  foetal  life,  to  malforma- 
tions in  the  rectum  itself,  and  to  imperfect  development  of  the  intes- 
tinal tract  either  above  or  below  the  c-xcal  valve.  It  may  also  be  due 
to  abnormal  development  of  the  sigmoid  flexure  and  colon,  both  in 
their  circumference  and  length,  to  sacculation  in  the  large  intestine, 
or  to  true  diverticuli,  as  has  been  pointed  out  by  Treves  and  Osier 
(Annals  of  Anatomy  and  Surgery,  Brooklyn,  1881).  Diaphragms  or 
folds  of  mucous  membrane  sometimes  project  into  the  lumen  of  the 
bowel  and  reduce  the  size  of  the  passage  to  a  greater  or  less  degree. 
These  diaphragms  more  frequently  occur  in  the  lower  portion  of  the 
intestinal  canal,  the  rectum,  and  sigmoid  flexure,  but  they  also  occur 
in  the  upper  portion  of  the  colon  and  in  the  small  intestine,  as  has 
been  pointed  out  by  Hloway  {op.  cit.,  p.  78). 

Martin,  in  his  little  work  Obstipation,  attempts  to  prove  that  the 
rectal  valves  or  Houston's  folds  are  the  cause  of  constipation  in  the 
large  majority  of  cases.  After  demonstrating  the  existence  of  the 
folds,  which  were  described  by  Houston,  Kohlrausch,  and  Otis,  he 
says :  ''"'  It  may  be  the  special  property  of  the  valves  in  certain  abnormal 
conditions  to  maliciously  obstruct  the  descent  of  the  faeces."  He  de- 
scribes three  forms  of  valvular  obstruction,  as  follows:  "First,  the  ana- 
tomic coarctation  of  the  valves  may  afford  an  exaggerated  physiologic 
resistance  to  the  descent  of  the  faeces.  Second,  congenital  hyperplasia 
of  the  rectal  valves  is  a  condition  classically  described  as  diaphragmatic 
stricture  or  membranous  SEeptum  in  the  abdominal  rectum.  Third,  hy- 
pertrophy of  the  rectal  valves  constitutes  the  classical,  annular  stricture 
of  the  abdominal  rectum." 

With  regard  to  his  first  proposition,  no  one  who  admits  the  exist- 
ence of  the  folds  as  anatomical  structures  can  deny  the  possibility  of 
their  retarding  the  descent  of  the  faeces  when  they  are  abnormally 
developed.  The  writer  has  studied  this  subject  in  an  unprejudiced 
manner  with  a  mind  open  to  conviction  from  everj-  point  of  view.  Hmi- 
dreds  of  cases,  in  many  of  which  the  valves  were  markedly  developed, 
and  overlapped  each  other,  have  been  examined,  and  yet  no  case  has 


532  THE   ANUS,   RECTUM,   AND   PELVIC  COLON 

As  a  matter  of  fact,  however,  iu  all  of  these  patients  the  change  of 
environment,  habits,  and  dietary  at  the  time,  or  after  the  beginning 
of  their  nervous  symptoms,  might  account  in  a  degree  for  their  con- 
stipation. These  facts,  however,  do  not  explain  the  occurrence  of  con- 
stipation in  almost  every  case  of  ataxia,  and  in  individuals  with  whom 
there  has  been  no  change  of  circumstances,  environments,  or  dietary. 
Whether  the  sympathetic  ganglia  and  the  plexus  of  Auerbach  and  Meiss- 
ner  take  part  in  the  sclerotic  process  or  not,  or  whether  it  is  simply 
an  involvement  of  the  cerebro-spinal  nerve-roots  and  centers  whicli 
control  the  inhibition  of  the  circular  muscular  fibers,  is  not  known;  but 
constipation  is  nearly  always  an  accompaniment  of  the  disease,  and  all 
remedies  directed  toward  it  are  of  only  temporary  benefit  unless  there 
is  concomitant  improvement  in  the  nervous  condition. 

Under  this  heading  one  may  group  that  type  of  constipation  termed 
spastic,  and  due,  according  to  Eosenheim  (Pathol,  u.  Therap.  der 
Krankh.  des  Darmes,  1893),  Kaczorowski  (Deutsche  med.  Wochen- 
schrift,  1888,  No.  1),  and  lUoway  {op.  cif.,  p.  88),  to  enterospasm. 

It  is  due  to  partial  or  general  tonic  contraction  of  the  muscles  of 
the  intestine,  the  circular  and  longitudinal  fibers  contracting  syn- 
chronously and  persistently,  and  thus  preventing  any  movement  of  the 
fgecal  mass. 

It  is  said  to  be  frequent  in  basilar  meningitis  and  pathological  pro- 
cesses that  produce  pressure  upon  the  pons  or  medulla  oblongata,  and  in 
lead-poisoning. 

The  partial  type  of  enterospasm  is  frequent  in  acute  gastritis  and 
intestinal  indigestion,  and,  according  to  Eosenthal,  may  be  produced 
by  chronic  gastric  catarrh.  The  same  author  speaks  of  this  condition 
as  "  crises  enteriques  "  occurring  in  the  course  of  tabes  dorsalis.  The 
constipation  in  this  type  of  cases,  as  can  be  readily  understood,  is  a 
matter  of  no  importance  compared  with  the  general  condition  which  pro- 
duces it.  It  increases  or  decreases,  following  the  course  of  the  disease 
of  which  it  is  a  symptom,  and  needs  no  therapy  of  its  own.  Entero- 
spasm occurs  during  the  course  of  neurasthenia,  hysteria,  and  acute 
nervous  excitement.  In  such  instances  the  management  of  the  neurosis 
is  the  part  of  the  physician;  the  constipation  will  take  care  of  itself. 

Uloway  states  that  partial  enterospasm  may  be  associated  with  atony 
of  the  intestinal  muscles,  which  opinion  seems  to  be  corroborated  by 
Eeynolds's  System  of  Medicine,  Eosenheim  (op.  cit.),  Fleiner  (Berliner 
klin.  Woehenschrift,  January,  1893),  and  C'herchewski  (Eevue  de  med., 
October  and  December,  1883).  He  includes  spasmodic  stricture  of  the 
rectum  and  contraction  of  the  sphincter  ani  as  types  of  enterospasm. 
These  conditions,  however,  being  due  in  the  large  majority  of  cases  to 
local  causes,  can  not  be  properly  included  in  this  category. 


CONSTIPATION,  OBSTIPATION,  AND   F^CAL  IMPACTION        533 

Local  and  Mechanical  Causes. — There  are  causes  which  act  in  a 
mechanical  manner  by  offering  an  obstruction  at  some  point  or  other 
of  the  intestinal  tract  to  the  passage  of  the  faecal  mass.  The  constipa- 
tion produced  by  these  has  been  termed  obstipation.  The  impression 
has  gone  abroad  in  certain  sections  that  this  term  is  applied  only  to 
those  obstructions  found  in  the  rectum,  particularly  those  produced  by 
inflammation,  hypertrophy,  or  malformation  of  Houston's  valves.  Such 
is  not  the  case.  Obstipation  consists  in  a  mechanical  obstruction  to  the 
passage  of  fsecal  matter  at  any  portion  of  the  intestinal  canal. 

In  children  it  is  frequently  due  to  the  imperfect  absorption  of  the 
sgeptum  dividing  the  rectum  and  the  anus  in  foetal  life,  to  malforma- 
tions in  the  rectum  itself,  and  to  imperfect  development  of  the  intes- 
tinal tract  either  above  or  below  the  csecal  valve.  It  may  also  be  due 
to  abnormal  development  of  the  sigmoid  flexure  and  colon,  both  in 
their  circumference  and  length,  to  sacculation  in  the  large  intestine, 
or  to  true  diverticuli,  as  has  been  pointed  out  by  Treves  and  Osier 
(Annals  of  Anatomy  and  Surgery,  Brooklyn,  1881).  Diaphragms  or 
folds  of  mucous  membrane  sometimes  project  into  the  lumen  of  the 
bowel  and  reduce  the  size  of  the  passage  to  a  greater  or  less  degree. 
These  diaphragms  more  frequently  occur  in  the  lower  portion  of  the 
intestinal  canal,  the  rectum,  and  sigmoid  flexure,  but  they  also  occur 
in  the  upper  portion  of  the  colon  and  in  the  small  intestine,  as  has 
been  pointed  out  by  Illoway  {op.  cit.,  p.  78). 

Martin,  in  his  little  work  Obstipation,  attempts  to  prove  that  the 
rectal  valves  or  Houston's  folds  are  the  cause  of  constipation  in  the 
large  majority  of  cases.  After  demonstrating  the  existence  of  the 
folds,  which  were  described  by  Houston,  Kohlrausch,  and  Otis,  he 
says:  "  It  may  be  the  special  property  of  the  valves  in  certain  abnormal 
conditions  to  maliciously  obstruct  the  descent  of  the  faeces."  He  de- 
scribes three  forms  of  valvular  obstruction,  as  follows:  "  First,  the  ana- 
tomic coarctation  of  the  valves  may  afford  an  exaggerated  physiologic 
resistance  to  the  descent  of  the  faeces.  Second,  congenital  hyperplasia 
of  the  rectal  valves  is  a  condition  classically  described  as  diaphragmatic 
stricture  or  membranous  saeptum  in  the  abdominal  rectum.  Third,  hy- 
pertrophy of  the  rectal  valves  constitutes  the  classical,  annular  stricture 
of  the  abdominal  rectum." 

With  regard  to  his  first  proposition,  no  one  who  admits  the  exist- 
ence of  the  folds  as  anatomical  structures  can  deny  the  possibility  of 
their  retarding  the  descent  of  the  fasces  when  they  are  abnormally 
developed.  The  writer  has  studied  this  subject  in  an  unprejudiced 
manner  with  a  mind  open  to  conviction  from  every  point  of  view.  Hun- 
dreds of  cases,  in  many  of  which  the  valves  were  markedly  developed, 
and  overlapped  each  other,  have  been  examined,  and  yet  no  case  has 


534  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

been  seen  in  which  anything  more  than  a  small  particle  of  faeces  has 
been  arrested  above  one  of  these  valves.  They  have  been  as  well  marked 
in  many  cases  which  did  not  suffer  the  least  from  constipation  as  they 
were  in  constipated  individuals.  Nineteen  valvotomies  have  been  per- 
formed, always  following  the  direction  of  Martin,  viz.,  that  a  hooked 
probe  introduced  into  the  center  of  the  valve  shall  not  slide  over  its 
edges  when  drawn  downward,  thus  demonstrating  the  obstructive  qual- 
ity of  the  valve  according  to  his  theory;  of  these  19  cases,  7  were  oper- 
ated upon  by  incision — according  to  the  methods  of  Martin — and  13 
by  the  Pennington  clip.  In  all  of  the  cases  a  certain  amount  of  benefit 
was  obtained  for  two  or  three  months,  but  after  this  time,  as  the 
patients  discontinued  the  hygienic  regimen  and  local  treatment  neces- 
sary to  the  healing  of  the  incised  valve,  the  old  symptoms  returned  to 
a  greater  or  less  degree.  Permanent  relief  was  accomplished  by  the 
operation  in  only  2  or  possibly  4  cases.  No  ill  effects,  however,  such 
as  stricture,  protracted  ulceration,  or  inflammation,  have  followed  the 
operation  in  any  of  these  cases.  Reasoning  from  the  anatomical  con- 
formation of  the  parts,  and  from  some  post-mortem  specimens  which 
have  been  observed — for  example,  the  one  from  which  Fig.  25  is  taken — 
the  opinion  results  that  obstipation  from  this  cause  may  occur,  but 
clinical  experience  does  not  prove  that  it  is  the  etiological  factor  in 
any  great  number  of  cases.  As  to  his  second  and  third  propositions, 
that  congenital  hyperplasia  of  the  rectal  valve  is  what  is  ordinarily 
known  as  diaphragmatic  stricture  or  membranous  seeptum  of  the  rectum, 
and  that  hypertrophy  of  these  valves  constitutes  annular  stricture  of  the 
rectum,  a  general  denial  must  be  entered.  In  the  first  place,  diaphrag- 
matic strictures  and  membranous  ssepta  occur  at  no  regular  locations  ex- 
cept at  the  juncture  of  the  rectum  with  the  anus,  entirely  below  the  site 
of  any  of  the  valves;  in  the  second  place,  the  compositions  of  such  sa?pta 
are  entirely  different  from  those  of  the  valves;  and  in  the  third  place, 
the  classical,  annular  stricture  of  the  rectum  has  neither  the  shape,  con- 
formation, nor  anatomical  structure  of  an  liypertrophied  valve.  Hyper- 
trophy of  the  valve  does  not  cause  it  to  extend  entirely  around  the  rec- 
timi,  but  simply  increases  its  anatomical  constituents  in  the  original 
site.  The  classical,  annular  stricture  of  the  rectum  entirely  surrounds 
this  organ,  and  is  ordinarily  as  thick  in  one  portion  of  the  circumference 
as  it  is  in  another;  again,  the  annular  stricture  is  composed  almost  en- 
tirely of  fibrous  material  covered  by  mucous  membrane,  and  is  developed 
from  the  submucosa.  Hypertrophy  of  the  rectal  valve  consists  in  thick- 
ening of  the  mucous  membrane,  an  increase  of  the  normal  constituents 
of  the  submucosa,  and  hypertrophy  of  the  muscular  wall  of  the  gut. 

While,  therefore,  the  possihility  is  admitted  that  abnormally  devel- 
oped or  hypertrophied  valves  may  produce  an  obstruction  to  the  passage 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        535 

of  the  fgecal  mass,  it  is  not  conceded  that  either  hypertrophy  or  hyper- 
plasia of  these  valves  constitutes  the  diaphragmatic  or  annular  stricture 
of  the  rectum.  .  This  view  is  sustained  by  the  elaborate  studies  of  hyper- 
trophied  valves  by  Pennington  and  Edwards  (Jour.  Amer.  Med.  Ass'n, 
December,  1900).    A  brief  account  of  their  observations  is  as  follows: 

"Mucosa. — The  mucosa  showed  epithelial  glands  containing  a  very 
large  percentage  of  goblet-cells.  No  other  pathological  process  was 
demonstrated  in  these  structures.  They  were  slightly  hypertrophied. 
There  was  nothing  to  indicate  an  atrophic  process  in  the  mucosa,  at  least 
at  this  time.  Between  the  glands  there  was  an  increase  of  tissue  which 
was  generally  round-cells,  though  some  spindle-cells  and  young  fibers 
were  apparent.  In  two  of  the  specimens  there  was  evident  local  infec- 
tion with  a  pus  organism,  the  focus  extending  into  the  submucosa.  The 
muscularis  mucosa  was  thickened. 

"  Submucosa. — The  submucosa  showed  a  great  increase  in  the  con- 
nective tissue,  which  was  in  bundles.  These  bundles  usually  ran  across 
the  long  axis  of  the  valve.  There  was  extensive  thickening  of  the  blood- 
vessel walls.  This  thickening  was  the  usual  type  of  endarteritis  ob- 
literans. The  sections  removed  from  the  valves  in  live  subjects  showed 
no  muscle  except  a  very  few  circular  fibers. 

"  In  a  section  made  from  a  cadaver,  in  which  the  valves  were  coarse 
and  resistant,  the  following  were  found:  the  circular  muscular  layer 
was  generally  hypertrophied;  the  longitudinal  layer  showed  slight  hyper- 
trophy, and  the  adventitia  external  to  the  muscular  layer  showed  an 
increase  of  white  fibrous  tissue  together  with  an  extensive  endarteritis 
obliterans." 

From  these  examinations  it  will  be  seen  that  there  was  no  evidence 
whatever  of  cicatricial  material,  such  as  goes  to  make  up  the  ordinary 
annular  stricture.  On  the  other  hand,  while  these  cases  are  said  to  have 
been  the  victims  of  constipation  along  with  colitis,  there  is  no  proof 
that  the  colitis  and  proctitis,  together  with  hypertrophy  of  the  valves, 
were  not  produced  by  the  retention  of  hardened  facal  masses  in  the 
rectum. 

This  idea  that  constipation  is  caused  by  the  rectal  valves  or  folds 
is  not  at  all  new.  Renauldin  (Diet,  des  sciences  med.,  1813,  vol.  vi,  p. 
257),  Copeland,  Kohlrausch,  and  Quain  (Diseases  of  the  Rectum,  1854) 
all  describe  cases  in  which  these  diaphragms  or  folds  have  resulted  in  the 
partial  or  complete  obstruction  of  fascal  passages.  There  is  therefore 
no  doubt  that  when  they  are  abnormally  developed  or  malformed,  as 
in  the  case  of  Renauldin,  the  folds  may  become  obstructive,  but  such 
cases  are  rare. 

Malformations. — The  cases  of  Renauldin  and  others  which  have  been 
referred  to  above  may  be  more  properly  classified  among  the  malforma- 


536 


THE  ANUS,  EECTUM,  AND  PELVIC  COLON 


tions  of  the  rectum;  with  them  one  may  include  other  malformations, 
such  as  congenital  arrests  of  development,  unusual  narrowness  at  the 
csecal  valve,  and  partial  atresia  of  the  anus. 

A  child  ^\•ho  presented  all  the  symptoms  of  a  chronic  constipation, 
with  recurrent  appendicitis,  was  seen,  in  whom,  upon  opening  the  abdo- 
men, there  was  no  appendicitis  whatever,  but  a  congenital  narrowing  of 
the  esecal  valve  and  of  the  ileum  for  two  feet  above  its  entrance  into  the 
CEecum.  To  the  eye  there  was  an  absence  of  muscular  development  in 
the  small  intestine  at  this  point.  The  Bauhinian  valve  was  so  tight  that 
a  very  small  fwcal  mass  pushed  forward  through  the  narrow  ileum 
failed  to  pass.  By  the  use  of  the  finger  and  invagination  of  the  small 
intestine  through  the  valve,  the  latter  was  divulsed,  after  which  the 
mass  passed  with  ease.  The  vermiform  appendix  was  removed,  but  it 
was  not  diseased.     Since  the  operation  the  patient's  bowels  have  moved 

regularly,  and  his  health  has 
greatly  improved.  The  chief 
cause  of  constipation  in  this 
patient  was  the  abnormal  nar- 
rowness of  the  ileo-caecal  valve 
and  imperfect  development  of 
the  ileum. 

Nothnagel  (Beitriige  zur 
Physiol,  u.  des  Darmes,  Ber- 
lin, 1884:)  describes  a  condi- 
tion which  he  calls  congenital 
hyperplasia  of  the  colon.  The 
patient  in  whom  it  was  ob- 
served gave  the  history  of  con- 
stipation from  infancy.  There 
was  an  innnense  development 
of  tlie  colon  and  large  accu- 
mulations of  fffical  material  in 
it.  The  interesting  case  of 
Futterer  and  Mittendorf  exhibits  a  remarkable  dilatation  or  diverticu- 
lum of  the  sigmoid  flexure  removed  from  a  boy  fourteen  years  of  age  in 
which  constipation  was  the  most  marked  symptom  (Fig.  178,  Illoway, 
op.  cit.,  p.  77).  Such  instances  are  curiosities,  but  less  marked  diverticuli 
of  the  intestine  are  by  no  means  unique,  and  they,  too,  cause  consti- 
pation. 

Bnteroptosis.— Displacements  of  tlie  intestines  are  not  infrequent 
causes  of  constipation.  Hosenlieim  claims  that  the  most  frequent  dis- 
placement of  the  large  intestine  takes  place  at  the  hepatic  flexure. 
This,  however,  is  not  the  experience  of  a  large  majority  of  observers. 


■'t.jy 


Fig.  178. — Malformation  of  the  Sigmoid  Flexi 


CONSTIPATIOX,  OBSTIPATIOX,  AXD   F.ECAL  IMPACTIOX 


00  1 


Prolapse  of  the  transverse  colon  is  the  most  frequent  type;  it  is  car- 
ried along  with  the  stomach  in  many  cases  of  gastroptosis.  In  such 
the  colon  forms  a  loop  representing  somewhat  an  inverted  U  or  M. 
The  fa?cal  material  after  it  has  passed  the  hepatic  flexure  drops  do\m 
into  the  loop  and  must  be 
again  lifted  directly  up- 
ward against  the  force  of 
gravity,  as  has  been  before 
described,  and  consequent- 
ly there  is  an  obstruction 
to  its  passage.  Persons 
with  this  condition  invari- 
ably suffer  from  a  greater 
or  less  degree  of  chronic 
constipation;  and  when  the 
bowels  and  stomach  are 
lifted  up  into  their  proper 
places  and  held  so  by  prop- 
erly adjusted  bandages,  the 
constipation  is  materially 
relieved. 

Acute  Flexures.  —  One 
of  the  chief  causes  of  con- 
stipation, and  one  to  which 
more  importance  is  at- 
tached than  to  any  other 
form  of  mechanical  ob- 
struction excejDt  stricture,  is  acute  flexure  between  the  rectum  and 
sigmoid.  In  the  normal  condition  the  empty  sigmoid  lies  in  the  pelvis 
between  the  rectum  and  bladder  or  uterus,  thus  causing  an  acute  flexure 
between  these  two  organs  (chajDter  on  Anatom}-).  In  cases  of  pelvic  in- 
flammation, peritonitis,  or  cellulitis,  it  not  infrequently  happens  that 
it  becomes  adherent  to  the  rectum  or  to  the  floor  of  the  pelvis,  thus 
becoming  limited  in  its  motions  and  prevented  from  rising  up  into  the 
abdominal  cavity,  thus  straightening  out  the  tract  between  it  and  the 
rectum  (Figs.  179  and  180).  Under  such  circumstances  an  obstruction 
to  the  passage  of  the  fsecal  mass  at  this  flexure  is  inevitable. 

This  condition  can  be  demonstrated  by  the  use  of  the  pneumatic  sig- 
moidoscope. "Where  the  pelvic  colon  is  normally  mobile,  inflation 
will  cause  it  to  rise  up  into  the  abdominal  cavity  and  allow  the  straight 
tube  to  pass  easily  into  tlie  canal.  Allien,  however,  on  account  of  such 
adhesions,  obstructions  in  the  shape  of  tumors,  or  too  short  a  meso- 
sigmoid,  this  flexure  can  not  be  straightened  out,  it  is  with  the  gi'eatest 


Fig.  179. — Accte  Flexcee  of  the  Sigmoid  ox  the 
Eectum.     (From  photograph  by  Pennington.) 


538 


THE  xVXrS,   RECTUM,  AND  PELVIC  COLON 


difficulty,  and  sometimes  even  impossible,  for  one  to  introduce  a  tube  of 
even  moderate  size  beyond  the  recto-signioidal  juncture. 

In  one  ease  operated  upon,  the  sigmoid  was  prevented  from  rising 
by  the  vermiform  appendix  passing  downward  across  its  anterior  surface 

and  adhering  to  the  peritoneum  of  the 
pelvis,  just  to  one  side  of  the  bladder. 
Attempts  were  made  during  several 
months  to  introduce  a  straight  tube 
into  this  woman^s  rectum,  and  they  al- 
ways caused  great  pain  until  after  the 
vermiform  appendix  was  loosened  from 
its  attachment  and  removed.  As  soon 
as  this  was  done,  the  sigmoid  sutured  to 
the  abdominal  wall,  and  the  patient  had 
recovered  from  the  immediate  effects 
of  the  operation,  it  was  possible  to  in- 
troduce the  tube  without  any  difficulty, 
and  the  patient's  bowels  moved  without 
pain,  an  experience  which  she  had  not 
enjoyed  for  many  years.  A  similar 
case  to  this,  observed  in  a  post  mortem, 
is  represented  in  Fig.  181.  Adhesive 
bands  from  peritonitis  occasionally  pass 
across  the  pelvic  cavity  and  interfere 
with  the  movement  of  the  sigmoid  iiexure.  There  may  be  inter- 
ference with  this  movement  by  the  adhesion  of  appendices  epii^loicse 
of  the  sigmoid  to  the  pelvic  wall.  These  adhesive  bands  not  only 
obstruct  the  movement  of  the  sigmoid  flexure  and  thus  cause  constipa- 
tion, but  they  also  sometimes  cross  the  pelvic  colon,  forming  diver- 
ticuli  above  them,  and  thus  occasion  constipation  by  their  actual  ob- 
struction of  the  canal.  These  flexures  and  adhesions  are  among  the 
most  frequent  causes  of  obstinate  constipation  in  women. 

Spasm  of  the  Sphincter. — H}^ertrophy  of  the  external  sphincter  and 
levator  ani  muscles  are  causes  of  constipation.  Mathews  lays  great 
stress  upon  the  influence  of  the  external  sphincter  in  the  causation  of 
this  condition;  he  holds  that  the  large  majority  of  the  cases  of  con- 
stipation arise  from  spasm  or  hypertrophy  of  this  muscle,  and  states 
that  in  many  of  the  cases  in  which  constipation  has  been  apparently 
relieved  by  operations  upon  hremorrhoids,  the  real  benefit  has  been 
derived  from  the  divulsion  of  the  sphincter.  There  is  no  doubt  a  large 
amount  of  truth  in  what  he  says  upon  this  subject,  but  the  cause  of 
the  hypertrophy  or  spasm  of  tlie  muscle  remains  to  be  explained.  It 
may  be  induced  by  pressure  from  a  prolapsed  uterus,  tumors  of  the 


Fig.   Isu. — Adhesion   of    Sigmoid  to 
THE  Eectum,  causing  Acute   Flex- 

UKE      AT     THEIK      JUNCTION.        (FrOUl 

pbotograpli  by  Pennington.) 


CONSTIPATION,  OBSTIPATION,  AND  F.ECAL   IMPACTION        539 


pelvis,  inflammation  of  the  rectum,  deep  urethra,  or  bladder;  other 
reflex  disturbances  may  also  occasion  it,  as  T\-ill  be  seen  in  the  chapter 
upon  the  neuroses  of  the  rectum. 

Fissure  in  ano  or  irritable  ulcers — in  fact,  ulceration  of  any  kind 
about  the  margin  of  the  anus,  or  just  -n-ithin  the  rectum,  will  occasion 
it.  Under  such  circumstances  the  fascal  movements  are  retarded  or  pre- 
vented by  a  twofold  action.  First,  the  actual  obstruction  caused  by 
the  sphincter;  and  second,  the  disinclination  upon  the  part  of  the 
patient  to  have  a  movement  which  will  occasion  more  or  less  distress. 
It  is  this  fear  in  the  first  place  which  occasions  the  constipation  in  acute 
fissure,  and  when  the  fissure  has  once  healed,  the  hypertrophy  of  the 
sphincter  which  has  been  occasioned  by  it  comes  in  to  play  the  part 
of  obstructor  to  the 
passage.  The  levator 
ani  muscle  is  also  sub- 
ject to  similar  irrita- 
tions, and  it  may  also 
play  a  part  in  the  pro- 
duction of  obstij^ation. 

Spasm  of  the  circu- 
lar fibers  of  the  intes- 
tine at  the  juncture  of 
the  sigmoid  and  rectum 
may  have  an  influence 
in  the  production  of 
constipation.  O'Beirne 
and  others  have  pointed 
out  that  whenever  a 
bougie  has  once  passed 
through  this  aperture 
it  is  verv'  likely  to  be 
followed  by  a  feecal 
movement;  it  excites 
an  inclination  to  go  to 
stool,  and  upon  a  sec- 
ond examination  a  short 
time  afterward  one  will 
almost  invariably  find 
an  increased  amount  of 
fffices  in  the  rectum,  thus  showing,  according  to  his  view,  that  the 
spasm  of  the  circular  fibers  had  prevented  the  descent  of  the  faeces. 

Foreign  Bodies. — The  presence  of  foreign  bodies  in  the  intestinal 
tract  may  also  become  the  occasion  of  chronic  or  acute  constipation. 


Fig.  181. — IxrLAiniATOET  Adhesion  of  the  Appendix,  bixd- 
1X&  THE  Sigmoid  to  the  Anterior  Surface  of  the  Sacrum 

AND    PREVENTING   ITS   RISING    OUT    OF   THE    PeLVIC    CaVITY. 


540  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

The  introduction  of  these  bodies  through  the  anus  will  usually  result 
in  an  acute  type;  whereas  those  which  are  formed  in  the  tract,  such  as 
concretions  and  enteroliths,  are  of  slow  development,  and  likely  to  result 
in  chronic  constipation  and  eventual  obstruction.  Certain  foreign  bod- 
ies which  pass  through  the  intestinal  canal,  having  been  swallowed, 
may  also  occasion  this  condition.  The  swallowing  of  false  teeth  has 
several  times  been  reported  as  resulting  in  constipation.  Prune-pits, 
fruit-seeds,  gall-stones,  and  small  particles  of  indigestible  food  have  fre- 
quently formed  the  nucleus  around  which  have  accumulated  the  salts 
found  in  the  intestinal  contents,  until  they  have  produced  large  con- 
cretions or  aggregations  which  obstruct  the  canal  and  thus  occasion 
either  chronic  constipation  or  complete  obstruction. 

Masses  of  hair  have  been  found  obstructing  the  intestinal  canal. 
Many  suppose  that  these  aggregations  are  dermoid  cysts  which  have 
ruptured  into  the  intestinal  canal,  but  such  is  not  the  case.  They  are 
ordinarily  found  in  patients  who  are  in  the  habit  of  biting  their  hair 
or  mustache  and  swallowing  it;  in  one  case  a  mass  of  this  kind  had 
formed  just  above  the  ca^cal  valve,  measuring  5^  inches  in  circumfer- 
ence and  8  inches  in  length.  Another  mass  of  this  kind  which  was 
removed  from  the  stomach  measured  9  inches  from  end  to  end,  and 
4^  inches  in  circumference  in  its  widest  part.  In  both  of  these  cases  the 
ha])it  of  biting  the  ends  of  the  hair  (which  was  worn  in  a  braid)  was 
clearly  made  out.  Many  other  foreign  bodies  have  been  found  to  cause 
constipation,  an  interesting  review  of  which  will  be  found  in  Treves's 
work  upon  intestinal  obstruction,  and  in  the  cases  quoted  by  Illoway 
{op.  cit.). 

Extra-iniestinal  Ohslrt/dions. — Finally,  as  causes  of  constipation  one 
should  always  bear  in  mind  the  fact  that  pressure  may  be  exerted  ui)on 
the  intestines  in  any  portion  of  their  tract,  and  thus  occasion  retarda- 
tion of  the  fffical  current.  Hydatids  of  the  liver,  tumors  of  the  spleen, 
kidneys  and  stomach  are  nearly  always  associated  with  greater  or  less 
constipation,  owing  to  their  pressure  upon  the  transverse  or  descending 
colon.  Subinvolution  and  displacements  of  the  uterus  very  frequently 
cause  it.  It  is  needless  to  mention  the  fact  that  a  fibroid  or  ovarian 
tumor  may  occasion  the  same  results.  These  conditions  should  always 
be  diagnosed  in  any  search  for  the  causes  of  constipation,  and  no  favor- 
able prognosis  can  ever  be  offered  so  long  as  they  exist. 

With  regai'd  to  strictures  of  the  rectum  and  sigmoid,  as  has  been 
described  in  the  chapter  upon  that  subject,  they  always  produce  a  con- 
stipation at  first,  and  afterward  result  in  a  combination  of  this  condition 
with  a  nagging,  teasing  rliarrhcea  which  masks  the  constipation.  The 
diagnosis  of  these  and  the  differentiation  between  the  malignant  and 
cicatricial  type  have  been  given  in  the  chapters  upon  those  subjects. 


CONSTIPATION,  OBSTIPATION,  AND   P^CAL  IMPACTION        54  L 

Intra-intestinal  tumors,  such  as  polypi,  adenomata,  papilloma, 
fibroma,  etc.,  may  all  occasion  constipation,  but  in  the  large  majority 
of  instances  the  efforts  of  Nature  to  rid  herself  of  these  neoplasms  result 
in  an  increase  of  peristalsis  and  diarrhoea. 

Intussusception  and  Prolapse. — Intussusception  of  the  intestine  in 
any  portion  of  its  extent  results  ordinarily  in  an  acute  obstruction. 
Illoway  and  Johnston  both  include  it  under  the  causes  of  constipation, 
and  perhaps  there  are  instances  in  which  a  mild  degree  of  intussuscep- 
tion may  result  in  an  acute,  temporary  attack  which  is  relieved  either 
by  the  sloughing  off  of  the  intussuscepted  portion  of  the  gut  or  by 
the  reduction  of  the  intussusception.  A  case  of  this  kind  was  reported 
to  the  writer  in  a  private  communication  by  Thomas,  of  Charleston, 
W.  Va.  The  j)atient  was  seized  on  January  12,  1901,  with  a  high 
temperature,  intense  pain  and  aching  in  the  limbs  and  back,  and  a 
severe  diarrhoea,  which  continued  for  ten  days  in  spite  of  treatment. 
The  patient  suffered  from  great  pain  in  the  rectum,  together  with 
nausea,  vomiting,  and  distention  of  the  abdomen  to  such  an  extent 
that  intestinal  obstruction  was  feared.  Under  rectal  irrigation  the 
patient  passed,  at  the  end  of  five  days,  a  section  of  bowel  about  6  inches 
in  length.  Immediately  after  this  the  symptoms  of  obstruction  sub- 
sided, and  the  patient  gradually  recovered.  Thomas  states  that  the  sec- 
tion passed  was  a  part  of  the  sigmoid  flexure,  as  he  could  see  the  circular 
line  of  granulation  at  the  point  where  the  gut  sloughed  off  about  8 
inches  above  the  anus. 

This  condition  is  rarely  so  mild  in  its  manifestations  and  symptoms 
as  to  be  classed  among  the  ordinary  causes  of  constipation.  On  the 
other  hand,  that  form  of  procidentia  of  the  rectum  termed  prolapse  of 
the  third  degree,  which  really  consists  in  an  intussusception  of  the  upper 
portion  of  the  rectum  or  sigmoid  into  the  ampulla,  is  quite  frequently 
productive  of  constipation.  Patients  suffering  from  this  condition  claim 
to  be  constipated,  and  yet  their  bowels  thoroughly  empty  themselves 
at  regular  periods;  the  sensation  of  uncompleted  defecation  in  these 
cases  is  caused  by  the  pressure  of  the  prolapsed  or  intussuscepted  gut 
upon  the  sensitive  margin  of  the  anal  aperture.  This  condition  is  dis- 
cussed in  the  chapter  on  Prolapse  of  the  Eectum. 

Stone  in  the  Bladder,  Stricture,  and  UretJiral  Diseases. — Stone  in  the 
bladder,  stricture,  and  urethral  diseases  may  all  result  in  constipation 
owing  to  reflex  spasm  and  subsequent  hypertrophy  of  the  sphincter  mus- 
cles. In  the  same  way  an  enlarged  prostate,  both  by  its  reflex  influence 
and  its  pressure  upon  the  rectum,  may  result  in  this  condition. 

Willy  Meyer  has  reported  (N.  Y.  Academy  of  Medicine,  February, 
1901)  the  fact  that  in  his  series  of  operations  for  enlarged  prostate  by 
the  Bottini  method  he  has  seen  several  cases  of  obstinate  constipation 


5-J:2         THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

relieved  of  that  as  well  as  of  the  dysuria.  The  author's  experiences 
with  that  operation  have  not  been  so  fortunate  in  the  relief  of  the  con- 
stipation. 

Diagnosis. — Constipation  must  be  distinguished  from  fa?cal  impac- 
tion and  intestinal  obstniction.  Before  deciding  that  either  exists,  one 
must  determine  that  the  patient's  functional  habits  are  abnormal.  What 
constitutes  constipation  in  one  does  not  in  another.  Wliere  a  patient 
has  regular  and  satisfactory  movements  without  any  local  or  constitu- 
tional disturbances,  even  if  the  periods  are  somewhat  widely  separated, 
it  is  to  be  presumed  that  this  is  normal,  and  the  habit  should  not  be 
interfered  with. 

Regularity  without  effort,  and  the  discharge  of  faecal  material  pro- 
portionate to  the  amount  of  food  consumed,  are  the  essential  requisites 
of  normal  defecation.  The  impairment  of  either  of  these  features  in 
the  line  of  inadequate  amounts,  or  prolonged  retention  requiring  in- 
creased effort  to  obtain  a  passage,  constitutes  constipation.  When  these 
have  been  determined,  a  search  for  the  cause  in  some  one  of  the  condi- 
tions which  have  been  enumerated  should  be  instituted.  Careful  in- 
quiry, abdominal  palpation,  and  digital  and  instrumental  examination 
are  all  necessary  to  come  to  a  proper  diagnosis  in  such  cases. 

"WTien  one  or  more  of  these  conditions  has  been  shown  to  exist,  they 
may  be  the  cause,  but  in  the  local  conditions  about  the  lower  end  of  the 
rectum  one  should  be  very  careful  in  his  prognosis  as  to  the  results  of 
their  cure  upon  the  constipation,  for  frequently  they  are  only  complica- 
tions and  not  its  causes. 

Between  acute  constipation,  faecal  impaction,  and  intestinal  obstruc- 
tion it  is  not  always  easy  to  draw  the  dividing  line.  They  may  all  be 
brought  about  by  the  same  causes,  and  produce  in  the  beginning  similar 
symptoms.  In  acute  constipation  there  is  at  first  simply  an  omission  in 
the  regular  movements  of  the  bowels,  which  may  persist  for  an  indefinite 
period  without  any  marked  symptoms.  When  constitutional  symptoms 
develop  they  consist  in  some  griping,  lack  of  appetite,  had  taste  in  the 
mouth,  a  little  heaviness  or  disinclination  to  mental  activity,  and  occa- 
sionally symptoms  of  autoinfection,  such  as  elevated  temperature,  rapid 
pulse,  and  more  or  less  aching  pains  over  the  body. 

In  impaction  the  patient  may  suffer  from  all  of  these  symptoms,  and 
yet  at  the  same  time  have  abnormally  frequent  passages.  The  author 
has  known  a  patient  to  suffer  from  a  continuous  diarrhoea  for  six  weeks, 
and  finally  develop  acute  mania  with  hallucinations  and  loss  of  memory, 
apparently  from  no  other  cause  than  an  impaction  of  faeces  in  the  sig- 
moid flexure.  The  impacted  mass  being  lodged  in  a  saccule  or  diver- 
ticulum of  the  colon  or  ampulla  of  the  rectum,  permits  fluid  stools  to 
pass  around  or  to  one  side  of  it.     This  causes  an  irritation,  inducing 


CONSTIPATION,  OBSTIPATION,  AND   F^CAL   IMPACTION        543 

frequent  stools,  and  thus  the  patient  is  often  misled  into  the  belief  that 
he  is  suffering  from  diarrhoea.  In  simple  constipation  and  in  impaction 
there  is  always  a  channel  for  the  escape  of  gases  from  the  bowels.  In 
complete  obstruction  the  lumen  of  the  gut  is  entirely  occluded  by  or- 
ganic changes  in  the  caliber,  by  some  foreign  substance  becoming  im- 
pacted in  a  narrow  portion  of  the  channel,  or 'by  intussusception,  volvu- 
lus, or  acute  flexure  in  the  gut. 

In  obstruction  the  constitutional  symptoms  manifest  themselves 
very  early.  The  torminse  are  severe,  the  abdomen  distends,  nausea  and 
vomiting  come  on  soon  in  the  disease,  the  ejecta  are  at  first  fluid  and 
bilious  and  afterward  faecal;  the  patient's  pulse  becomes  very  rapid  and 
feeble;  he  has  cold  perspiration  and  general  weakness,  and  after  one  or 
two  enemas  the  fluid  injected  will  return  unstained  by  f  seal  matter.  The 
importance  of  an  early  distinction  between  these  different  conditions 
can  not  be  overestimated.  The  utmost  patience  and  dependence  upon 
natural  functions  is  requisite  in  the  treatment  of  constipation;  in  faecal 
impaction  repeated  enemas,  faecal  solv-ents,  and  gentle  distention  of  the 
gut  by  air  is  advisable,  rather  than  to  undertake  radical  surgical  opera- 
tions. If  the  mass  is  within  reach  from  the  rectum,  ansesthetization  and 
breaking  it  up  are  justifiable,  but  too  great  haste  may  be  exercised  in  this. 

In  intestinal  obstruction,  however,  prolonged  manipulation  and 
efforts  to  overcome  the  condition  by  enemas,  infiations  of  the  intestine, 
and  therapeutic  remedies  are  not  only  useless  but  seriously  jeopardize 
the  patient's  life.  Eadical  measures  must  be  u.ndertaken  at  once,  either 
through  the  formation  of  an  artificial  anus  above  the  point  of  obstruc- 
tion or  by  the  removal  of  the  obstructing  cause.  In  order  for  this  to 
prove  successful,  the  diagnosis  and  operation  must  be  done  early  in  the 
obstruction.  A  close  study  of  the  S5^mptoms  is  therefore  of  paramount 
importance. 

Thus  far  we  have  discussed  those  features  common  to  both  the  acute 
and  chronic  forms  of  constipation.  In  the  consideration  of  symptoms 
and  treatment  we  must  separate  the  two. 

Acute  Constipation. — Acute  constipation  is  a  temporary  interruption 
of  the  normal  activity  of  the  bowels  usually  produced  by  functional 
rather  than  mechanical  causes.  It  occurs  in  the  course  of  acute  con- 
stitutional and  infectious  diseases,  or  during  periods  of  excitement,  great 
mental  strain,  changes  in  business  or  environment,  and  in  travel  where 
the  conveniences  are  poor,  and  the  diet,  water,  and  habits  of  life  are 
irregular  and  changeable. 

Symptoms. — In  a  few  cases  the  omission  of  a  stool  causes  a  certain 
amount  of  inconvenience,  but  in  the  large  majority  an  interruption  of 
one,  two,  or  three  days  may  take  place  without  any  serious  disturbances. 
The  symptoms,  when  any  are  aroused  by  such  an  omission,  consist  in 


544  THE  ANUS,   RECTUM,   AND   PELVIC  COLON 

slight  heaviness  about  the  sacrum,  heat  and  fulness  in  the  rectum  or 
pelvis,  and  more  or  less  hebetude.  When  the  bowels  move  after  the 
interruption,  the  mass  may  be  perfectly  normal  or  it  may  be  hard  and 
lumpy,  requiring  effort  to  pass  it;  the  quantity  expelled  is  ordinarily 
much  larger  than  normal,  and  frequently  the  first  stool  is  followed  by 
two  or  three  smaller  ones  before  the  sigmoid  and  rectum  are  emptied. 
The  feeling  of  fulness  and  tenderness  in  the  rectum  and  anus  may  re- 
main for  some  time  after  the  first  movement,  and  an  examination  at  this 
time  will  demonstrate  a  congestion  of  the  hemorrhoidal  veins  and  an 
oedematous  condition  of  the  muco-cutaneous  tissue  around  the  anus. 
All  of  these  symptoms  may  disappear  spontaneously,  or  it  may  be  neces- 
sary to  flush  the  colon  and  have  recourse  to  purgative  medicines  before 
they  are  relieved.  Elevation  of  temperature  and  accelerated  pulse-rate 
are  frequently  but  not  invariably  present  in  acute  constipation.  There 
may  be  tenesmus  or  violent  paroxysms  of  pain,  and  occasionally  symp- 
toms of  obstruction,  but  these  symptoms  are  rare  except  in  cases  with 
organic  obstructions.  A^olvulus  or  intussusception  may  also  produce 
them.  In  simple  acute  constipation  they  all  subside,  and  tlie  patient  is 
relieved  as  soon  as  a  good  fa?cal  movement  is  obtained. 

Habitual  negligence  of  the  calls  of  Nature  and  recurrent  attacks 
of  acute  constipation  result  in  a  decrease  of  sensibility  and  atony 
or  loss  of  expulsive  power  in  the  rectum  which  ends  in  the  chronic 
form. 

Treatment. — When  the  condition  develops  suddenly  and  has  only 
lasted  for  a  day  or  two  in  patients  whose  bowels  have  previously  been 
regular,  it  is  ordinarily  wise  not  to  interfere  too  actively  at  first.  Espe- 
cially is  this  true  where  mental  absorption  or  changes  in  habits  or 
environment  account  for  the  condition;  such  cases  almost  invariably 
right  themselves.  But  when  there  are  symptoms  like  headache,  sleepiness, 
tympanites,  pain  in  the  back,  in  the  inguinal  regions,  or  about  the  anus, 
then  it  becomes  necessary  to  move  the  bowels.  If  a  simple  enema  does 
not  relieve  the  symptoms  at  once,  a  rectal  and  sigmoidal  examination 
should  always  be  made  to  determine  whether  foreign  bodies  or  me- 
chanical obstructions  are  present.  When  it  is  simple  constipation  the 
enema  should  be  repeated,  and  after  all  the  hardened  faecal  masses  in 
the  rectum  and  sigmoid  flexure  are  removed,  some  mild  laxative  may 
be  given  in  order  to  stimulate  the  peristaltic  action  of  the  small  intestine 
and  upper  colon,  and  thus  empty  them.  There  is  nothing  better  in 
these  acute  cases  than  minute  doses  of  calomel,  one-tenth  to  one-fourth 
of  a  grain,  with  bicarbonate  of  soda  in  triturate  tablets;  the  one-tenth- 
grain  tablets  may  be  repeated  every  half  hour,  or  the  one-fourth-grain 
every  hour  until  the  bowels  have  been  moved.  Neither  shoiild  be  con- 
tinued longer  than  eight  hours. 


COXSTIPATION,  OBSTIPATIOX,  AND   FAECAL   IMPACTIOX        545 

Another  remedy  which  has  acted  well  in  such  cases  lias  been  sulphate 
of  magnesia  one  ounce,  and  bicarbonate  of  soda  one  dram  dissolved 
in  four  ounces  of  water;  a  tablespoonful  of  this  is  given  every  half  hour 
■until  the  bowels  move. 

Eochelle  salts,  citrate  of  magnesia,  Seidlitz  powders,  phosphate  of 
soda,  and  the  various  saline  waters  may  also  be  used,  but  the  above  simple 
remedies  will  ordinarily  effect  just  as  good  results  as  the  most  com- 
plicated aperients.  Wliere  there  is  tenesmus,  tympanites,  pain,  and 
griping,  hot  applications  to  the  abdominal  wall  often  give  great  relief; 
and  occasionally  the  constipation  yields  to  a  full  dose  of  morphine  ad- 
ministered hypodermically,  thus  indicating  the  spasmodic  nature  of  the 
condition.  "When  a  low  enema  is  given  by  an  ordinary  syringe  and  fails 
to  produce  a  fsecal  movement,  long  rectal  tubes  (24  to  30  inches  in 
length)  may  be  introduced,  with  the  patient's  hips  elevated  and  his 
shoulders  lowered  so  as  to  allow  large  quantities  of  water  to  flow  slowly 
into  the  colon.  In  this  way  as  much  as  4,  6,  or  even  10  pints  of  water 
may  be  introduced,  and  distressing  symptoms  are  relieved  either  by  the 
loosening  up  of  an  impacted  ftecal  mass,  or  possibly  by  the  undoing 
of  a  volvulus  or  intussusception.  The  syringe  holding  the  water  should 
be  elevated  not  more  than  2  feet  above  the  patient's  body,  so  that  the 
fluid  will  rrm  in  very  slowly.  A  little  turpentine  and  milk  of  asafcetida 
may  be  added  to  the  injection,  and  they  will  materially  aid  in  stimu- 
lating peristalsis.  In  one  case  of  acute  constipation  it  was  possible  to 
give  immediate  relief  by  the  lifting  up  of  a  subinvoluted  uterus  which 
had  through  a  sudden  jolt  been  carried  downward  and  backward,  and 
become  impacted  against  the  sacrum,  thus  occluding  the  rectum. 
With  a  Sims's  uterine  repositor  the  organ  was  lifted  into  position,  not 
without  some  pain,  however,  and  within  a  short  time  a  full  and  free 
action  of  the  bowels  resulted.  Another  case  of  this  kind  was  relieved 
by  the  evacuation  of  a  large  hsematocele  which  developed  in  the  pelvic 
cavity  and  thus  practically  occluded  the  rectimi.  Large  abscesses,  either 
of  the  ischio-rectal  fossae  or  the  superior  pelvi-rectal  spaces,  may  occa- 
sion acute  constipation,  which  salines  and  other  laxatives  aggravate 
rather  than  relieve.  The  evacuation  of  the  abscess  cavity  results  in 
immediate  relief.  Acute  inflammation  and  spasm  of  the  bowels  may 
produce  a  temporary  constipation,  but  ordinarily  it  is  of  very  short 
duration,  and  soon  resolves  itself  into  a  diarrhoea.  ]\Iorphine  relieves 
these  cases.  The  slowly  acting  cathartics  are  not  advisable  in  this 
variety  of  constipation. 

Chroxic  Coxstipatiox. — Chronic  constipation  consists  in  inade- 
quate or  abnormally  infrequent  facal  passages,  and  prolonged  retention 
of  the  fscal  materials  in  the  intestinal  canal.  It  occurs  at  all  ages,  in 
every  class,  and  is  produced  by  a  variety  of  causes,  as  has  been  shown.  • 
35 


546  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

Syinploinii. — The  typical  symptoms  in  chronic  constipation  are  grad- 
ually increasing  periods  between  the  fecal  movements,  associated  with 
progressive  liardening  of  the  faecal  mass,  and  decreasing  desire  to  defe- 
cate. In  the  beginning  there  are  ordinarily  no  constitutional  symp- 
toms; the  patient  simply  notices  that  his  stools  are  smaller,  harder, 
drier,  in  lumps  of  various  sizes,  and  generally  of  a  dark-brown  or  green- 
ish-black color.  Later  on  he  will  observe,  perhaps,  that  these  masses  are 
coated  with  mucus,  which  may  or  may  not  be  tinged  with  blood.  Fre- 
quently gelatinous  masses  of  coagulated  mucus  will  precede  or  follow 
the  fascal  mass,  and  sometimes  one  will  observe  in  such  passages  parti- 
cles of  undigested  food,  like  pieces  of  meat,  fruit  or  vegetable  material, 
and  foreign  substances. 

When  this  condition  has  existed  for  a  greater  or  less  period,  symp- 
toms of  indigestion  appear;  there  are  flatulence,  lack  of  appetite,  coated 
tongue,  distention  of  the  abdomen,  and  gaseous  eructations.  The  tongue 
is  usually  pale,  flabby,  furred  with  white  in  the  middle,  and  indented 
by  the  teeth  at  its  edges;  headache,  drowsiness,  and  mental  lethargy 
gradually  come  on;  the  patient's  rest  is  broken  by  bad  dreams,  and  he 
may  gradually  lose  flesh  and  strength.  Palpitation  of  the  heart,  dys- 
pnoea, and  occasionally  vertigo  and  dizziness,  accompany  the  condition. 
There  may  be  disturbances  of  vision,  tinnitus  aurium,  cardialgia  (Mel- 
hose,  Hufeland's  J.,  1841,  Bd.  xcii,  S.  105),  and  various  reflex  symptoms, 
as  follows: 

Uro-getntal  Syni'ptoms. — Constipation  is  frequently  the  cause  of 
urinary  disturbances  through  pressure  of  the  faecal  mass  upon  the  ure- 
ters, the  neck  of  the  bladder,  or  the  prostatic  urethra;  suppression  of 
urine  is  said  to  have  been  occasioned  by  it  (Barnwell,  Cincinnati  Med. 
News,  1875,  p.  553).  In  chronic  cases  the  urine  is  increased  in  quantity, 
the  color  is  darker,  and  the  solid  constituents  are  increased;  it  is  often 
loaded  with  urates,  but  oxaluria  is  one  of  the  most  constant  features. 
Occasionally  cases  are  seen  in  which  there  is  an  excessive  secretion  of 
urine  with  low  specific  gravity  and  clear  limpid  color.  In  these  cases 
there  is  no  evidence  of  glycosuria,  and  it  is  reasonable  to  suppose  that 
the  symptoms  are  purely  reflex. 

In  young  women  constipation  is  frequently  the  cause  of  catamenial 
disturbances,  hysteria,  and  chlorosis.  That  which  is  often  described  as 
chlorosis  or  anaemia  is  nothing  more  than  auto-intoxication  due  to  the 
prolonged  retention  of  faecal  material  in  the  intestinal  canal.  Anteflex- 
ion and  painful  menstruation  (Thomas),  together  with  chronic  inflam- 
mation of  the  uterus  and  its  appendages,  may  all  be  caused  by  the  pro- 
tracted retention  of  faecal  masses  in  the  sigmoid  and  rectum. 

Constitutional  Effects. — ]\Iuscular  rheumatism,  stiffness  of  the  joints, 
and  lack  of  tone  in  the  general  system  sometimes  result  from  prolonged 


CONSTIPATION,  OBSTIPATION,  AND  P^CAL  IMPACTION        547 

retention  of  fgecal  matter  in  the  intestine.  The  hair  and  finger  nails 
become  dry  and  brittle,  the  skin  is  sallow,  covered  with  silvery,  scaly 
epithelium,  or  is  often  wrinkled  and  parchment-like.  Sometimes  there 
is  acne,  prurigo,  urticaria,  or  furunculosis. 

Alterations  in  bodily  temperature  are  not  so  frequently  associated 
with  chronic  as  with  acute  constipation;  there  are  persons  who,  upon 
the  omission  of  one  day's  fsecal  movement,  will  develop  an  elevation 
of  bodily  temperature  of  3  or  4  degrees,  and  children,  from  no  other 
apparent  cause  than  accumulation  of  fgeces  in  the  intestinal  canal,  will 
have  temperatures  of  104°  to  106°  Fahr. 

General  practitioners  have  frequently  observed  the  fact  that  in 
the  course  of  continued  fevers  the  temperature  will  be  elevated  when 
the  bowels  have  not  been  moved  for  two  or  three  days,  and  it  is  a 
constant  experience  in  hospitals  that  the  temperature  of  surgical  cases 
will  gradually  rise  after  operative  procedures  until  the  bowels  have 
been  moved,  when  it  will  drop  to  normal,  and  remain  so  during  the 
whole  course  of  convalescence.  Johnston  (Lancet,  London,  1879,  vol.  ii, 
p.  239)  has  recorded  a  case  in  which  there  was  a  temperature  of  104.0°, 
pulse  180,  and  a  delirium  due  to  accumulated  fseces  in  the  intestinal 
tract.  Barnes  (Med.  Press  and  Circular,  1879,  p.  477),  Cabot  and 
Warren  (Boston  Med.  and  Surg.  Jour.,  1880,  p.  1571)  have  also  re- 
ported cases  in  which  there  was  great  elevation  of  temperature  due  to 
faecal  accumulations.  The  explanation  of  these  phenomena  lies  in  some 
influence  upon  the  heat  center  through  auto-intoxication  or  irritation 
of  the  mucous  membrane. 

Nervous  and  Mental  Symptoms. — In  children,  either  acute  or  chronic 
constipation  may  result  in  severe  nervous  phenomena,  such  as  St. 
Vitus's  dance,  epilepsy,  and  convulsions.  In  nervous  and  mental  dis- 
eases of  adults,  chronic  constipation  is  one  of  the  most  frequent  com- 
plications. In  hypochondria  and  melancholia  it  is  almost  always  pres- 
ent, and  may  act  as  an  exciting  cause  through  the  depressing  effect 
of  the  accumulated  fgecal  material,  the  auto-intoxication  from  its  putre- 
faction, and  also  through  the  overestimation  upon  the  part  of  the 
individual  of  the  necessity  of  daily  fgecal  movements.  As  has  been 
said,  this  "  daily  movement "  becomes  the  subject  of  unceasing  thought 
and  anxiety.  Pulitzer  (Wien.  med.  Presse,  1866,  S.  439)  and  Du- 
Jardin-Beaumetz  (Bull,  de  therapeut.,  Paris,  1875,  p.  179)  have  called 
attention  to  serious  hallucinations  and  loss  of  consciousness  in  indi- 
viduals suffering  from  constipation.  Mattel  (Bull,  de  I'acad.  de  med., 
vol.  XXX,  p.  870)  has  reported  a  case  of  aphasia  due  to  constipation 
and  fgecal  accumulation.  Every  alienist  has  probably  seen  cases  of 
temporary  mental  derangement  associated  with  fgecal  retention.  The 
following  interesting  instance  of  this  occurred  in  the  author's  practice: 


548  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

Mr.  A.  T.,  lawyer,  patient  of  Dr.  Frederick  Peterson,  had  been  suffering  from 
delusions,  hallucinations,  and  partial  unconsciousness  for  several  weeks  without 
any  apparent  cerebral  disease  to  account  for  the  same.  His  attack  had  begun  in  a 
diarrhoea  with  severe  pains  and  tenesmus,  which  continued  more  or  less  persist- 
ently except  when  he  was  under  the  influence  of  opiates.  This  pain  was  at  first 
referred  to  the  lower  portion  of  the  abdomen  and  to  the  rectum.  An  examination 
with  the  pneumatic  proctoscope  established  the  presence  of  an  impacted  faecal  mass 
in  the  sigmoid  flexure,  together  with  a  small  ulceration  at  the  juncture  of  the 
rectum  with  the  sigmoid.  The  faecal  mass  was  loosened  and  removed  by  the  use 
of  solutions  of  ox-gall  and  oil,  together  with  pneumatic  distention  of  the  bowel. 
Within  a  few  days  the  patient's  mental  condition  cleared  up  and  he  became  per- 
fectly rational. 

Such  conditions  are  doubtless  due  to  an  alteration  of  the  blood 
resulting  from  the  absorption  of  gases  and  putrefactive  materials  from 
the  intestine.  Vostch,  quoted  by  Johnston  (Pepper's  System  of  Medi- 
cine, vol.  ii,  p.  647),  has  reported  10  cases  of  suicide  in  which  there 
were  displacements  of  the  colon  and  evidences  of  chronic  constipa- 
tion. He  also  quotes  Laudenberger  of  Stuttgart,  who  observed  that 
in  94  autopsies  of  insane  individuals,  one-seventh  suffered  from  con- 
stipation and  displacements   of   the  transverse   colon. 

Treatment. — The  treatment  of  any  individual  case  of  constipation 
will  depend  upon  its  cause.  In  children  it  is  ordinarily  due  to  malforma- 
tion, unnatural  diet,  or  some  local  disease  of  the  rectum  and  anus,  the 
pain  of  which  causes  them  to  avoid  having  movements.  Malformations 
usually  will  manifest  themselves  in  the  first  few  days  of  infant  life, 
and  should  be  remedied  in  accordance  with  the  methods  before  described 
(see  chapter  on  Malformations). 

Every  accoucheur  when  he  delivers  a  child  should  make  it  a  practice 
to  introduce  his  finger  into  the  infant's  anus,  and  determine  whether 
the  connection  between  it  and  the  rectum  has  been  perfectly  estab- 
lished or  not.  It  does  the  child  no  harm  to  dilate  the  sphincter  slightly 
at  this  time;  it  stimulates  the  respirations,  gives  vent  to  the  accumu- 
lated meconium,  and  also  relieves  the  physician  of  any  responsibil- 
ity as  to  future  accidents  through  the  possible  malformation  of  these 
parts. 

In  breast-fed  children  there  will  be  less  danger  of  constipation  than 
in  those  brought  up  by  the  bottle.  In  these  days  of  modified  milk 
and  artificial  foods,  it  is  presumed  that  the  mother's  milk  is  absolutely 
duplicated.  There  is  a  difference,  however,  between  normal  breast 
milk  and  chemically  prepared  reproductions  of  the  same,  which  science 
has  been  unable  to  solve,  and  while  many  infants  are  raised  to  a  strong 
and  healthy  childhood  upon  cow's  milk  and  its  modifications,  it  is  very 
frequently  found  more  than  difficult  to  regulate  their  bowels  and  pre- 
vent constipation  and  diarrhoea  under  this  regimen. 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        549 

In  many  books  on  paediatrics  it  is  taught  that  the  mother  should 
place  the  child  upon  a  vessel  at  a  certain  hour  every  day  in  order  to 
establish  the  habit  of  faecal  movements  at  certain  periods.  The  estab- 
lishment of  such  a  habit  is  devoutly  to  be  desired,  but  this  method  of 
doing  it  is  a  most  fruitful  source  of  fissures,  haemorrhoids,  and  pro- 
lapsus of  the  rectum.  If,  in  order  to  bring  about  a  daily  stool,  it  is 
necessary  to  stimulate  the  mucous  membrane  of  the  intestine,  it  is 
better  to  give  the  child  a  small  enema  of  cold  water  at  a  certain  hour 
every  day.  Ordinarily  in  bottle-fed  infants  the  constipation  is  due 
to  a  lack  of  sugar  in  the  food;  this  may  be  relieved  by  adding  certain 
quantities  of  sugar  of  milk  to  it.  Sometimes  a  lack  of  oil  or  richness 
in  the  milk  will  occasion  it;  in  such  cases  an  increase  in  the  cream 
will  frequently  overcome  the  constipation  and  regulate  the  child's 
bowels.  The  addition  of  lime-water  to  milk  for  feeding  children  is 
very  likely  to  result  in  constipation.  The  prolonged  use  of  bismuth 
and  such  salts  in  the  treatment  of  summer  diarrhoea  is  also  likely  to 
develop  it,  and  should  always  be  followed  by  a  laxative  in  order  to 
clean  these  substances  out  of  the  intestinal  canal  after  the  diarrhoea 
is  under  control. 

The  use  of  castile-soap  bougies  or  cones  often  stimulates  a  child's 
bowels  to  movement  in  cases  with  a  tendency  toward  constipation,  and 
if  they  are  carefully  introduced  no  harm  is  likely  to  follow;  in  fact, 
they  are  among  the  best  remedies.  After  children  have  begun  to  eat 
solid  food,  the  regulation  of  their  diet  is  ordinarily  all  that  is  neces- 
sary to  overcome  the  condition.  The  modern  refinement  of  foods  has 
a  tendency  toward  the  production  of  constipation  in  that  it  removes 
all  the  indigestible  and  rough  portions,  thus  taking  away  one  of  the 
chief  elements  in  the  stimulation  of  peristaltic  action  in  the  bowels. 
Feeding  upon  white  bread,  prepared  starch,  predigested  foods,  arrow- 
root, and  such  substances  as  have  no  indigestible  material  is  a  most 
prolific  cause  of  constipation  in  children  from  one  to  seven  years  of 
age.  Oatmeal  and  cracked  wheat  in  moderate  quantities,  together  with 
a  little  sugar  and  milk,  are  most  excellent  foods  for  children,  in  that 
they  furnish  an  adequate  amount  of  roughness  to  stimulate  the  bowels 
to  normal  action.  Fruits  are  useful,  but  they  have  too  great  a  tend- 
ency to  produce  fermentation,  and  consequently  diarrhoea.  After  the 
age  of  three  to  four  years  a  diet  containing  a  reasonable  amount  of 
waste,  cold  baths,  massage  to  the  abdomen,  and  outdoor  exercise  are 
the  best  methods  of  avoiding  or  treating  constipation.  There  is  noth- 
ing like  a  brisk  run  in  the  fresh  air,  with  full,  deep  respirations  and 
chest  movements,  to  induce  a  normal  action  of  the  bowels.  Cold  baths 
are  also  very  stimulating  to  peristaltic  action;  at  the  same  time  that 
the  bath  is  given  thorough  rubbing  and  massage  of  the  abdominal  walls, 


550  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

especially  in  the  line  of  the  colon,  upward  upon  the  right  side,  trans- 
versely, and  then  downward  upon  the  left,  will  be  found  beneficial. 

The  habitual  use  of  drugs  in  constipated  children  should  be  avoided. 
Occasional  doses  of  calomel,  rhubarb  and  soda,  or  glycerin  and  phos- 
phate of  soda  act  as  useful  bridges,  but  they  should  not  be  used  too 
often.  Castor-oil,  while  an  excellent  remedy  in  diarrhoea,  cleaning 
out  the  bowel,  and  serving  as  a  sedative  to  the  mucous  membrane, 
always  leaves  a  tendency  to  constipation  behind  it  in  whatever  form 
it  is  administered.  Sulphate  of  magnesia  acts  just  as  w^ell  and  does 
not  leave  this  tendency.  The  stronger  cathartics  should  not  be  admin- 
istered to  children. 

Constipation  in  school-girls  is  a  question  of  the  utmost  importance. 
The  little  attention  given  to  the  regularity  of  the  bowels  in  girls  in 
boarding-schools  calls  for  the  severest  criticism.  The  rules  and  regu- 
lations of  the  recitation-room  are  important,  but  they  are  not  para- 
mount to  the  proper  functional  action  of  the  patient's  bowels.  If 
teachers  only  realized  that  the  call  for  a  natural  movement  if  resisted 
passes  over  and  does  not  recur  again  under  ordinary  circumstances  for 
considerable  periods  of  time,  and  that  any  individual  retaining  faecal 
materials  for  longer  periods  than  normal  begins  to  absorb  the  toxic 
principles  of  those  materials,  and  thus  becomes  heavy,  sleepy,  and 
lethargic,  they  would  understand  the  importance  of  granting  excuses 
from  study  or  the  recitation-room  for  such  purposes  at  all  times.  No 
person  can  do  good  brain  work  with  an  intestine  full  of  old,  decomposing 
faecal  matter.  The  large  majority  of  cases  of  constipation  in  women 
have  been  generated  in  school-rooms,  boarding-schools,  or  through  mock 
modesty  and  the  stringent  regulations  of  polite  society. 

The  proper  location  of  the  toilet-room  is  of  more  importance  to  a 
family  or  school  than  the  elegance  of  their  parlors.  This  should  be 
so  placed  that  neither  weather,  darkness,  nor  publicity  should  ever 
interfere  with  its  use.  The  accommodations  should  also  be  adequate 
for  all  necessities.  One  water-closet  is  entirely  inadequate  for  a  family 
of  five  or  six,  and  when  one  sees  large  boarding-houses  or  schools  wuth 
only  two  little  dark  water-closets  one  w^onders  how  the  inmates  remain 
as  healthy  as  they  do. 

The  tenements  and  public  institutions  of  nearly  all  cities  are 
criminally  negligent  in  these  matters.  In  one  institution  with  which 
the  author  is  connected  he  found  upon  beginning  his  service  there  one 
toilet-seat  for  seven  hundred  men.  They  stood  in  long  lines  to  await 
their  turn,  many  of  them  losing  their  desire  before  the  opportunity 
for  relief  came,  and  others  were  forced  through  the  urgency  of  their 
calls  to  use  the  buckets  in  their  cells,  thus  fouling  the  atmosphere 
of  the  entire  hall.     This  is  an  exceptional  instance,  but  the  same  con- 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        551 

dition  prevails  only  in  a  less  degree  in  many  institutions  outside  of 
New  York  city.  Its  influence  was  exhibited  in  the  large  number  of 
rectal  cases  which  had  to  be  treated  in  the  hospital  of  the  institution 
at  that  time. 

In  adult  life  the  prevention  and  often  the  cure  of  constipation 
may  be  accomplished  by  a  change  of  personal  habits.  Lethargic  in- 
dividuals leading  sedentary  lives  should  be  urged  to  take  exercise  in 
the  open  air,  and  to  avoid  sitting  too  long  in  poorly  ventilated  rooms. 
Those  who  are  given  to  eating  largely  and  to  stimulating  their  appe- 
tites with  wines,  condiments,  and  a  rich  dietary,  should  be  advised 
to  live  more  simply;  a  certain  amount  of  fat  with  a  meat  diet  should 
always  be  taken;  in  vegetables  the  fibrous,  indigestible  material  has 
its  uses,  and  should  be  eaten  as  well  as  the  saccharine  and  starchy 
portions.  The  eradication  of  those  fibrous  portions  of  the  food  often 
results  in  such  a  decreased  amount  of  refuse  matter  that  an  inadequate 
faecal  mass  is  formed;  it  is  important  that  the  food  should  contain  a 
sufficient  quantity  of  roughness  to  stimulate  peristaltic  action,  and  to 
furnish  a  proper  amount  of  fgecal  material  for  the  intestine  to  act  upon. 

Alcoholic  liquors,  coffee  in  excess,  and  especially  tea,  should  be 
avoided  in  these  cases,  inasmuch  as  they  all  cause  congestion  of  the 
liver,  with  improper  secretion  of  bile,  and  consequent  constipation. 

Attention  to  the  functions  of  the  skin  is  frequently  of  much  benefit 
in  constipation.  Cold  baths,  with  shower  or  needle-baths  to  the  abdo- 
men, followed  by  vigorous  rubbing,  is  often  productive  of  great  good. 
The  temperature  of  the  water  must  vary,  however,  with  individual  cases. 
Cold  baths  are  depressing  to  some,  and  in  such  cases  tepid  water  should 
be  used. 

Stomachic  indigestion  is  very  frequently  the  precursor  of  constipa- 
tion, and  yet  it  is  often  the  result  of  the  same.  At  any  rate  the 
digestive  functions  should  always  be  looked  into  very  thoroughly,  and 
properly  regulated  in  every  attempt  to  cure  a  case  of  constipation. 

With  these  general  remarks  one  comes  to  the  management  of  the 
actual  condition  of  deficient  or  retarded  fgecal  movements.  Assuming 
that  a  patient's  digestion  is  good,  that  he  takes  a  sufficient  quantity 
of  proper  food,  and  yet  passes  an  inadequate  amoimt  of  ftecal  matter 
and  at  too  widely  separated  periods,  the  question  arises.  What  is  to 
be  done  for  him? 

In  the  majority  of  cases  the  patients  will  have  run  the  gamut  of 
cathartic  medicines  before  the  physician  is  consulted.  The  popular 
and  too  often  the  professional  treatment  of  constipation  consists  in 
the  administration  of  some  drug,  usually  without  any  reference  to  the 
cause.  By  referring  to  the  section  on  Etiology  one  will  see  a  very 
large  array  of  conditions  which  may  produce  constipation;  they  are 


552  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

functional  and  organic,  chemical  and  mechanical.  The  food  may  be 
improper  in  quantity  or  quality;  peristalsis  of  the  intestine  may  be 
deficient  through  enervation,  or  it  may  be  spasmodic;  the  secretions 
of  the  intestine  may  be  deficient,  so  that  the  mass  is  too  dry  to  be 
moved  along  the  intestinal  canal;  the  organs  may  be  displaced;  there 
may  be  strictures,  mucous  folds,  neoplasms,  concretions,  foreign  bodies, 
and  a  hundred  other  conditions  either  obstructing  the  faecal  passage 
and  delaying  it,  or  giving  rise  to  catarrhal  diseases,  ulcerations,  or 
other  conditions  of  the  bowel  which  limit  functional  activity,  and  thus 
prevent  the  movements. 

The  treatment  of  chronic  constipation  therefore  consists  in  the 
treatment  of  the  various  conditions  which  cause  it.  By  careful  ex- 
amination of  the  faeces  one  may  learn  whether  the  stomachic  or  intes- 
tinal digestion  is  incomplete.  For  the  treatment  of  these  digestive 
conditions  the  reader  is  referred  to  the  works  of  Van  Valzah  and  Nisbit, 
Ewald,  Xothnagel,  and  Hemmeter. 

Where  there  are  evidences  that  the  constipation  is  due  to  impair- 
ment of  the  intestinal,  hepatic,  or  pancreatic  secretions,  drugs  directed 
to  the  alteration  of  these  conditions  are  advisable.  Minute  doses  of 
calomel  or  protoiodide  of  mercury  unquestionably  stimulate  the  secre- 
tions of  the  glands.  At  the  same  time  one  may  administer  some  of 
the  modern  aids  to  intestinal  digestion,  such  as  diastase,  pancreatin, 
taka-diastase,  peptenzyme,  and  lactopeptine. 

^Yhe^e  there  is  evidence  of  fermentation  and  excessive  flatulence, 
some  antiferment,  such  as  bismuth,  boric  acid,  salol,  naphthol,  or  beta- 
naphthol,  may  be  combined  with  the  pancreatin. 

If  the  stools  are  hard  and  dry,  thus  indicating  an  insufficiency  of 
fluid,  large  drafts  of  water  after  and  between  meals  should  be  ad- 
vised. Occasionally  this  fluid  may  be  administered  before  meals,  es- 
pecially if  there  is  any  evidence  of  excessive  mucous  secretion  in  the 
stomach.  Two  or  three  tumblers  of  hot  water  before  meals  will  some- 
times succeed  in  overcoming  a  chronic  constipation,  in  which  the  most 
powerful  laxatives  of  the  pharmacopasia  have  failed.  The  fact  that  so 
many  patients  are  benefited  by  visits  to  watering  resorts,  where  the 
water  itself  has  no  particular  medicinal  value,  is  evidence  enough  that 
it  is  lack  of  fluids  in  the  system  and  regulation  of  habits  that  account 
in  a  large  measure  for  their  constipation. 

Where  there  is  evidence  of  catarrhal  conditions  of  the  bowel  and 
intestine  throughout,  these  should  be  treated  according  to  the  meth- 
ods laid  down  in  the  chapter  upon  that  subject.  Change  of  climate, 
regulation  of  diet,  and  outdoor  exercise  in  moderation,  are  of  the 
utmost  benefit  in  such  cases  as  these.  Where  such  changes  are  not 
possible,  exercise  and  regulation  of  the  diet  should  be  carried  out  at 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        553 

home.  If  the  stomachic  digestion  can  not  be  made  efficient,  the  food 
should  be  predigested  or  the  nitrogenous  elements  in  the  diet  should 
be  reduced,  and  the  patient  put  upon  a  carbohydrate  diet.  Where  the 
condition,  however,  is  one  of  intestinal  indigestion,  as  is  the  case  in 
the  majority  of  instances,  then  the  diet  should  consist  largely  of  nitro- 
genous elements,  such  as  animal  soups,  broths,  fresh  meats,  eggs,  fish, 
fowl,  and  oysters,  with  a  sufficient  quantity  of  green  vegetables  to  pro- 
duce an  adequate  faecal  mass  which  will  stimulate  the  colon  to  peri- 
staltic action.  The  fresh  vegetables  should  consist  of  spinach,  aspara- 
gus, kohlrabi,  chicory,  kale,  onions,  salsify,  peas,  cabbage,  celery,  string- 
beans,  etc.  The  best  bread  in  these  cases  is  that  made  of  gluten  flour; 
but  the  crust  of  well-baked  French  bread,  toasted  bread,  rye  bread,  or 
bread  made  of  Indian  meal,  are  admissible  in  moderate  quantities. 
Potatoes,  pastry,  rich  puddings,  and  confectionery  should  not  be 
allowed.  Along  with  this  diet  the  administration  of  a  sufficient  quan- 
tity of  glycerin  to  stimulate  the  intestinal  glands  to  secretion,  and 
thus  increase  the  fluid  element  of  the  fseces,  is  often  of  great  benefit. 
Small  doses  of  phosphate  of  soda  also  serve  this  purpose. 

W.  Gill  Wylie  says  that  in  the  majority  of  gynaacological  patients 
coming  under  his  care,  the  constipation  is  due  to  a  deficient  amount 
of  fluid  in  the  intestinal  canal,  and  that  he  obtains  the  best  results  by 
the  administration  of  half  an  ounce  each  of  castor-oil  and  glycerin  be- 
fore each  meal,  together  with  large  drafts  of  water  between  meals;  while 
one  would  expect  this  treatment  to  produce  a  diarrhoea,  after  the  first 
few  days  it  seems  only  to  keep  the  stools  soft  and  to  continue  com- 
paratively normal  actions.  The  one  thing  to  be  guarded  against  in 
the  method  is  that  it  should  not  be  stopped  too  suddenly. 

In  cases  in  which  the  constipation  is  due  to  displacement  of  the 
intestines  or  enteroptosis,  the  treatment  is  very  difficult.  The  wearing 
of  an  abdominal  bandage,  such  as  has  been  advised  by  Van  Valzah,  will 
frequently  accomplish  a  great  deal  of  relief.  Its  use  must  be  con- 
tinued, however,  for  long  periods,  and  the  patient  should  be  required 
to  eat  very  small  quantities  of  food  at  any  one  time,  and  thus  avoid 
overloading  the  stomach  and  pressing  it  downward,  for  usually  dis- 
placement of  the  colon  is  due  primarily  to  the  displacement  of  this 
organ.  Displacement  of  the  splenic  flexure  or  of  the  descending  colon 
rarely  if  ever  produces  constipation,  but  that  of  the  transverse  colon 
does.  The  question  of  opening  the  abdomen  and  suturing  the  trans- 
verse colon  back  into  position  is  one  that  has  frequently  suggested 
itself,  but  the  writer  has  never  had  an  opportunity  to  put  it  into  practice, 
nor  is  he  aware  of  any  one  who  has  operated  for  this  purpose. 

The  influence  of  an  acutely  flexed,  displaced,  or  adherent  sigmoid 
in  the  production  of  constipation  has  been  fully  discussed.    As  a  natural 


554  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

consequence,  when  this  condition  of  affairs  exists,  the  pelvic  colon  rarely 
empties  itself  completely,  and  the  patients  all  suffer  more  or  less  from 
constipation,  auto-intoxication,  irritation  of  the  gut,  and  frequent  ulcer- 
ation. Where  the  sigmoid  flexure  is  normally  movable  and  not  con- 
stricted, the  sigmoidoscope  should  pass  through  the  rectum  and  into  it 
without  any  great  difficulty.  In  many  cases  of  chronic  constipation  it 
has  been  found  to  be  almost  impossible  to  introduce  the  tube  on  account 
of  acute  flexures  and  adhesions;  even  after  it  has  passed  the  constriction 
of  the  flexure  it  can  only  be  carried  a  short  distance  upward,  because 
the  sigmoid  can  not  be  lifted  up  into  the  abdominal  cavity  and  thus 
straightened  out. 

In  these  cases  the  constipation  is  accompanied  with  flatulency,  heavi- 
ness in  the  limbs,  and  the  patients  are  never  completely  relieved  by 
a  movement.  Some  benefit  is  obtained  for  them  by  the  passage  of  a  soft 
Wales  bougie  which  is  left  in  position  for  ten  or  fifteen  minutes;  the 
elastic  curvature  of  the  instrument  lifts  the  gut  up,  stretches  the  ad- 
hesions, and  partially  straightens  out  the  curvature.  The  same  end  may 
be  accomplished  by  pneumatic  dilatation  of  the  sigmoid,  a  method  that 
will  be  referred  to  later.  These  means  often  fail  to  give  permanent 
relief.  Under  such  circumstances  the  patient  should  be  advised  to  have 
the  adhesions  broken  up,  and  if  necessary  to  have  the  pelvic  colon 
sewed  to  the  abdominal  wall  so  as  to  prevent  a  recurrence  of  the 
condition.  This  operation,  called  colopexy,  is  described  in  the  chapter 
on  Procidentia.  The  author  has  performed  it  fifteen  times,  and  while 
it  has  not  always  been  done  for  simple  constipation,  upon  inquiry  he 
has  learned  that  there  has  not  been  a  single  case  in  which  the  move- 
ment of  the  bowels  was  not  free  and  comfortable  after  it.  The  pa- 
tients in  whom  the  operation  was  done  for  constipation  alone  have 
all  been  perfectly  relieved.  One  may  say  that  opening  the  abdominal 
cavity  is  not  justified  by  the  condition  of  constipation;  but  in  these 
days  of  aseptic  surgery  one  does  not  hesitate  to  do  this  operation 
for  simple  exploration,  and  it  would  seem  to  be  justified  as  a 
means  of  searching  for  the  cause  of  constipation  or  of  relieving 
that  cause  when  it  has  been  discovered  by  other  methods.  In  the 
case  in  which  the  sigmoid  was  held  down  by  the  appendix,  the  patient 
had  not  had  a  movement  for  years  without  pain  and  difficulty;  she 
had  become  accustomed  to  the  use  of  all  sorts  of  laxatives  and  cathartics 
in  large  doses,  and  there  was  therefore  a  certain  amount  of  atony  and 
insensibility  of  the  intestinal  walls  which  required  some  stimulation 
in  order  to  keep  up  the  peristaltic  action.  Before  the  patient  got  out 
of  bed  after  the  operation  she  was  having  regular  stools  daily  upon 
taking  3  drops  of  the  fluid  extract  of  cascara,  and,  at  the  present  writing, 
sixteen  months  later,  she  takes  no  laxatives  whatever. 


CONSTIPATION,  OBSTIPATION,  AND   F^CAL  IMPACTION        555 

Insufflation  of  air  into  the  sigmoid  flexure  will  frequently  lift  it 
out  of  the  pelvis,  especially  if  the  patient  be  put  in  the  knee-chest 
posture,  and  the  distention  of  the  gut  will  often  result  in  a  free  fgecal 
movement  shortly  thereafter.  Not  only  is  this  the  case,  but  it  fre- 
quently follows  that  the  patient  will  have  regular  movements  for  two 
or  three  days  after  the  inflation. 

The  author  had  in  his  practice  a  woman  who  came  to  his  office 
twice  a  week  on  account  of  a  most  obstinate  constipation;  there  was 
no  dryness  of  the  fgecal  mass,  and  the  quantity  seemed  to  be  compara- 
tively normal,  but  the  sigmoid  flexure  was  always  bent  down 
in  the  jDclvis  until  it  was  inflated  by  pneumatic  pressure 
and  thus  lifted  up.  This  treatment  resulted  in  a  movement 
shortly  afterward,  and  often  on  the  two  or  three  following 
days.  Two  months^  treatment  in  this  way  practically  cured 
her.  In  these  cases  the  air  is  not  allowed  to  escape  through 
the  tube  before  the  latter  is  withdrawn;  in  fact,  it  should 
remain  and  the  sigmoid  be  distended  so  that  when  the  pa- 
tient rises  it  will  stay  outside  of  the  pelvic  cavity  and  allow 
the  small  intestines  to  fall  down  below  it,  thus  keeping  it 
above  and  in  a  somewhat  straight  line  with  the  rectum,  by 
which  means  the  passage  of  fgecal  matter  into  the  latter  organ 
is  facilitated.  By  flooding  the  sigmoid  flexure  with  liquids, 
such  as  saline  solution,  oil,  oil  and  glycerin,  boric-acid  solu- 
tions, and  simple  hot  water,  it  may  be  made  to  rise  upward 
in  the  abdomen;  such  injections  thus  aid  fgecal  movements 
in  a  mechanical  way  as  well  as  by  local  stimulation. 

Where  there  is  deficient  peristaltic  action  of  the  intes- 
tines, massage  is  one  of  our  chief  remedies;  no  method  is  as 
satisfactory  as  that  of  rolling  a  heavy  ball  over  the  colon,      I'ig-  182.— 
beginning  at  the  caecum  and  carrving  it  upward  and  across      ^ 

O  O  J         O  1  iliLECTRODE. 

in  the  line  of  the  transverse  colon,  and  downward  to  the 
sigmoid  flexure.  The  patient  should  get  a  small  cannon-ball  weighing 
3  or  4  pounds  and  cover  it  with  chamois-skin,  and  use  this  as  an 
instrument  of  massage;  balls  of  this  size,  however,  have  become  very 
scarce,  and  it  is  necessary  to  have  them  made  to  order.  They  can 
be  purchased  from  Mr.  Judd,  of  this  city,  or  they  can  be  made  at  home 
by  pouring  melted  lead  into  a  sand  mold.  An  ordinary  baseball  will 
do,  except  that  it  is  not  heavy  enough  to  give  the  pressure  necessary 
upon  the  colon. 

Electricity  may  be  used  in  these  cases;  the  positive  electrode  (Fig. 
182)  is  introduced  into  the  rectum,  and  the  negative  is  applied  along  the 
tract  of  the  colon  and  sigmoid  over  the  abdomen.  ISTo  doubt  some  cases 
have  materially  improved  while  the  electric  treatment  was  being  carried 


556  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

out.  but  it  has  been  a  question  as  to  whether  it  was  the  massage  pro- 
duced by  the  rubbing,  the  irritation  to  the  mucous  membrane,  or  the 
electricit}^  itself  which  benefited  the  patient.  Recently  much  has  been 
said  concerning  vibratory  treatment  of  constipation.  The  author  applies 
it  to  the  abdomen,  especially  over  the  line  of  the  colon  and  over  the 
lumbar  spine  through  a  rolling  vibratode,  and  to  the  rectum  and  sigmoid 
through  one  made  of  rubber  fourteen  inches  in  length.  From  his 
limited  experience  it  appears  to  be  useful  in  atonic  cases. 

In  such  cases  strychnine,  arsenic,  phosphorus,  phosphide  of  zinc, 
and  all  the  nerve  tonics  and  stimulants  which  are  at  our  command 
should  be  made  use  of  in  turn.  The  massage,  however,  with  the  heavy, 
covered  ball  has  proved  beneficial  in  more  cases  than  any  of  these 
remedies.  In  patients  whose  conditions  do  not  permit  of  their  taking 
proper  exercise,  massage  or  mechanical  movements  have  frequently 
proved  of  great  benefit;  in  old,  stout,  lethargic  individuals  they  are 
exceedingly  useful.  They  are  not  "  cure-alls,"  however,  as  some  of 
their  advocates  claim,  and  must  be  used  in  connection  with  proper 
local  and  general  treatment. 

Ulceration  and  inflammation  of  the  sigmoid  and  colon  are  spoken 
of  as  causes  of  constipation,  though  it  is  likely  that  they  much  more 
frequently  produce  diarrhoea.  When  the  ulceration  can  be  seen  through 
the  sigmoidoscope,  it  should  be  treated  locally  by  such  remedies  as  have 
been  advised  in  the  chapter  upon  that  subject. 

Thus  far  we  have  considered  the  treatment  of  constipation  when 
caused  by  conditions  in  the  intestinal  tract  above  the  rectum  proper. 
Within  this  organ  various  conditions  may  cause  it,  such  as  fissure, 
stricture,  foreign  bodies,  fistula,  neoplasms,  etc.  It  is  not  necessary 
to  reiterate  the  principles  of  diagnosis  and  tr&atment  of  these  dis- 
orders in  this  place.  There  are  a  few  conditions,  however,  which 
demand  special  mention. 

Spasm  of  the  Sphincter. — Mathews  (Diseases  of  the  Rectum,  p.  55) 
holds  that  the  large  majority  of  the  cases  of  constipation  are  due  to 
hypertrophy  and  spasm  of  the  external  sphincter.  Admitting  that 
this  may  offer  an  obstruction  to  isecal  passages,  one  must  give  some 
account  of  the  cause  of  such  hypertrophy  and  spasm.  The  sphincter 
muscle  is  not  continuously  in  a  state  of  spasm,  such  as  can  not  be  over- 
come by  the  inhibitory  power,  unless  there  is  some  inflammation  or 
irritation  present.  Whenever  this  has  been  relieved,  notwithstanding 
it  may  leave  the  s])hincter  in  a  hypertrophied  condition,  the  constant 
spasm  ceases.  The  nerves,  however,  may  be  left  in  such  a  sensitive 
state  that  the  pressure  of  the  faecal  mass  will  occasion  spasmodic  action 
of  the  muscle  and  thus  prevent  f?ecal  passages. 

The  true  cause  of  constipation  then  is  not  in   the  muscle  itself 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        557 

but  in  the  inflammation  or  the  sensitive  nerve  condition.  The  fact 
that  the  stretching  of  tlie  sphincter  often  relieves  constipation  is  proof 
enough  that  it  is  not  due  to  the  spasm,  for  we  know  that  a  spliincter, 
however  thoroughly  it  is  stretched,  if  it  is  not  ruptured,  will  resume 
its  tone  and  spasmodic  contraction  within  a  few  days;  stretching  it 
can  not  possibly  reduce  the  hypertrophy,  inasmuch  as  it  is  only  put 
at  rest  for  a  short  time  and  a  hypereemia  is  induced,  thus  giving  a 
greater  blood  supply  and  all  the  elements  for  increase  instead  of 
atrophy.  At  the  same  time  it  often  does  cure  obscure  fissures  and 
minor  anal  ulcerations  through  the  temporary  rest  which  it  gives  to 
the  parts,  and  along  with  these  the  constij)ation  disappears.  They 
are  the  causes  of  the  constipation  and  not  the  spasm  of  the  sphincter. 
There  are  cases  in  which  there  is  abnormal  contraction  and  fibrous 
degeneration  of  the  external  sphincter  muscle  occasioning  constipa- 
tion, but  when  such  is  the  case  the  condition  is  practically  one  of 
stricture. 

In  all  cases  of  constipation  with  this  contracted  type  of  sphincter, 
either  gradual  or  forcible  dilatation  of  the  muscle  should  be  prac- 
tised; at  the  same  time  one  should  not  be  too  positive  in  his  prognosis 
as  to  the  result  upon  the  constipation.  Wiere  a  fissure  can  be  clearly 
seen,  and  there  is  no  other  reason  for  the  constipation,  incision  is 
preferable  to  stretching,  the  relief  is  more  permanent  and  far  more 
certain,  and  the  operation  can  be  done  under  cocaine  without  general 
ansesthesia. 

HcBmorrhoids. — As  a  rule,  haemorrhoids  are  the  result  of  constipa- 
tion rather  than  its  cause,  and  operations  upon  them  for  the  relief 
of  this  condition  are  very  likely  to  result  in  disaijpointment.  A  large 
mass  of  inflamed  or  hypertrophied  hemorrhoids  may  obstruct  the  pas- 
sage of  hard  fsecal  masses  and  thus  intensify  the  constipation,  but 
they  are  rarely  the  exciting  cause.  In  cases  where  such  exist  in  con- 
nection with  constipation  due  to  local  conditions  higher  up  in  the 
bowel,  it  is  advisable  to  operate  upon  the  hemorrhoids  before  under- 
taking the  treatment  of  the  other  condition;  or  at  least  if  the  latter 
requires  operative  interference,  it  should  be  done  at  the  same  time. 
But  little  can  be  promised  a  patient  so  far  as  the  cure  of  constipation 
is  concerned  by  the  operative  treatment  of  hsemorrhoids  alone. 

Houston's  Valves. — Many  cases  of  constipation  have  recently  been 
reported  as  cured  by  incision  of  the  valves  of  Houston.  Martin,  of 
Cleveland,  first  introduced  this  operation  under  the  name  of  Valvotomy. 
His  method  is  as  follows:  The  patient  is  placed  in  the  knee-chest  posture 
and  a  tubular  speculum  of  30  millimeters  diameter  is  introduced  up  to 
the  projecting  valve.  The  resistance  of  the  valve  is  tested  by  the  use 
of  the  hook  (Fig.  183)  bent  at  an  acute  angle.     If  the  hook  holds  in 


558 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


the  valve  when  dragged  down  upon,  the  latter  is  said  to  be  abnormal 
and  to  require  section. 

The  patient  is  prepared  for  operation  by  having  the  bowels  thorough- 
ly cleansed  and  washed  with  antiseptic  solutions.  The  valve  to  be  di- 
vided is  first  fastened  by  the  volsella  forceps  or  long  tenaculum;  the 
hook  of  the  tenaculum  is  made  to  transfix  the  mucous  membrane  and 
fibrous  portion  of  the  valve  only  (Fig.  183).  The  depth  to  which  the 
valve  should  be  cut  is  determined  by  the  point  at  which  a  uterine  sound 
curved  to  three-quarters  of  a  circle  is  arrested  when  introduced  above 
the  valve  and  pulled  downward.  When  this  is  done  the  point  at  which 
the  probe  rests  will  be  shown  by  a  blanched  eminence,  and  the  distance 


Fig.  1S3. — Tzstixtt  Resistance  of  Valve  with  Maetix  Hook  i  Ilc-mmeter). 


between  this  and  the  free  border  of  the  valve  should  be  either  meas- 
ured, or  the  valve  should  be  transfixed  by  a  curved  bistoury  while  the 
probe  is  in  position,  somewhat  nearer  the  free  edge  than  the  point 
at  which  the  probe  presses.  After  having  determined  the  point  at 
which  the  incision  is  to  be  made,  the  valve  is  fastened  by  two  tenacula 
upon  either  side  of  this  point  (Fig.  184).  The  knife  (Fig.  185)  used  is 
a  special  device  of  Dr.  Martin.  The  transfixion  ought  to  be  made 
when  the  valve  is  at  right  angles  to  the  intestinal  wall,  and  not  when 
it  is  drawn  down.  In  order  to  avoid  pulling  the  valve  downward  in 
this  procedure,  Martin  advises  the  use  of  proctoscopes  of  different 
lengths,   so   that   they   will   just   reach   the   valve.     Having   made   a 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        559 


first  incision,  which  is  very  shallow,  with  the  sharp-curved  bistoury,  he 
then  takes  a  scalpel  (fastened  upon  a  similar  handle  to  that  of  the 
bistoury)  and  carries  his  incision  deeper.  In  his  first  paper  he  stated 
that  if  hsemorrhage  occurred,  he  was  in  the  habit  of  controlling  it  by 
the  application  of 
temporary  clamps. 
Later  on,  however, 
he  modified  this  by 
using  sutures  which 
bring  the  cut  edges 
of  the  mucous 
membrane  together. 
He  has  devised 
some  ingenious  in- 
struments for  in- 
troducing them, 
but  even  with  these 
the  operation  seems 
quite  difficult.  It 
is  questionable 
whether  the  sutur- 
ing does  any  good, 
as  primary  union  is 
not  likely  to  take 
place,  and  Martin 
says  that  he  has 
never  seen  a  hsem- 
orrhage  sufficient  to 
cause  him  any  great 
uneasiness. 

The  after-treat- 
ment he  describes 
as  follows :  "  Every 
day  the  wound 
is  inspected  and 
dressed  according 
to  the  nature  of  its  requirements,  and  after  the  first  two  or  three  days 
the  valve  should  be  carefully  subjected  to  divulsion  or  massage  by  the 
means  of  a  coactor.  Should  there  ensue  a  rectitis  or  a  granulating 
wound,  it  may  be  treated  by  the  means  of  an  atomizer,  by  the  use  of 
topic  applications  otherwise  administered,  or  by  lavage." 

Pennington,  after  having  had  1  case  of  peritonitis  and  another  in 
which  there  was  a  severe  haemorrhage  following  the  operation  as  above 


^^^m 

\ 

i   1 

1 

^-     ~, 

F 

^ 

'  ,M 

^J^ 

w^ 

Fig.  184.- 


-FlXATION    AND    InCISION    OF    VaLVE    AFTER    MaKTIN's 

Method  (Hemmeter). 


560  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

described,  devised  the  ingenious  clip  (Fig.  186)  which  severs  or  cuts  out 
an  elliptical  piece  from  the  free  border  of  the  rectal  valve.  This  clip 
is  applied  while  the  valve  is  in  its  normal  position  (Fig.  187),  and  by  its 
gradual  pressure  causes  a  necrosis  of  the  tissues,  thus  cutting  through 

the  folds  w4th- 
' '■'  •^Cwrmii^      out  any  danger 

and  if  the  peri- 
tonaeum   should 


Fig.  185— Maktin'8  Knives.  by  any  possibil- 

ity be  involved 
in  the  valve,  it 

causes  adhesions  between  the  two  layers  and  thus  prevents  perforation 
and  subseqvient  peritonitis.  Gant  has  devised  a  modification  of  this  clip 
(Fig.  188)  which  does  not  require  a  special  instrument  for  introducing 
it,  but  it  is  larger  and  more  likely  to  irritate  the  rectum.  This  is  a  safer 
and  simpler  method  of  operating  than  that  originally  devised  by  ]\Iartin, 
and  appears  to  accomplish  exactly  the  same  end  (Figs.  189,  190). 

Martin  states  that  he  has  operated  upon  more  than  a  hundred 
cases  by  this  method,  and  has  absolutely  cured  the  constipation  in 
almost  every  one.'  Pennington  relates  a  similar  experience,  as  do  also 
Cook,  of  Nashville,  and  Beach,  of  Pittsburg.  Earle,  of  Baltimore, 
Gant,  of  New  York,  and  the  author  have  employed  their  methods  in 
numerous  cases,  but  have  seen  permanent  ■  improvement  in  very  few 
cases.  Earle  states  that  recently  he  has  seen  2  cases  in  which  the 
operation  seems  to  have  effected  a  cure.  The  author  has  seen  some 
cases  in  which  there  were  inflammatory  and  connective-tissue  changes 
in  these  folds,  thus  constituting  crescentic  stricture  of  the  rectum; 
these  were  incised  with  much  benefit  to  the  patients,  but  they  suffered 
more  from  diarrhoea  than  constipation.    In  some  cases  in  which  he  oper- 


FiG.  186. — Pennington's  Clip  for  cutting  Rectal  Valves  and  the 
Instrument  for  applying  it. 

ated  upon  the  valves  there  was  an  immediate  increase  of  frequency  in  the 
f cecal  movements;  in  fact,  they  became  too  frequent,  and  the  patient 
suffered  from  more  or  less  tormina  and  griping.  As  the  operative 
wound  healed,  however,  these  conditions  disappeared  and  the  old-time 
constipation  returned.     In  1  case  in  which  he  operated  by  the  Pen- 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL   IMPACTION        561 

nington  clip,  the  movements  were  accelerated  from  the  very  day  that 
the  clip  was  put  on.  In  fact  during  the  whole  period  that  the  clip 
was  cutting  through  the  valve  the  patient  had  from  one  to  three  move- 
ments each  day.  Now  it  must  be  observed  that  these  movements 
occurred  before  the  clip  had  cut  through  and  while  the  valve  was  still 


Fig.  187. — Pennington's  Clip  Applied. 


intact.  The  obstruction  to  the  faecal  passages  could  not  therefore 
have  been  relieved,  and  we  must  look  to  some  other  influence  to  account 
for  their  increase.  This  influence  consists  in  the  irritation  of  the  intes- 
tine produced  by  the  incision  in  Martin's  method  and  by  the  pressure 
of  the  clip  in  Pennington's.  This  stimulation  continues  to  act  until 
the  ulcer  is  healed,  and  therefore  no  conclu- 
sions can  be  drawn  from  this  period. 

If,  as  is  advised  by  Martin,  the  patient's 
diet  and  habits  be  regulated,  if  his  environ- 
ments and  methods  of  life  be  changed  so  as 
to  be  most  conducive  to  the  regular  action 
of  the  bowels,  this  increased  activity  may  be 

maintained,  and  the  patient  by  establishing  systematic  habits  with 
regard  to  stool  during  this  healing  period  will  be  relieved  of  his 
constipation.  But  these  methods  will  often  relieve  it  without  cut- 
ting the  valves.  The  passage  of  bougies,  rectal  tubes,  and  instruments 
for  the  treatment  and  examination  of  the  operative  field,  the  introduc- 
tion of  ointments,  sprays,  and  antiseptic  washings,  are  all  conducive 
36 


Fig.   188. — Gant's   Clip    for 

CUTTING  EeCTAL   VaLVES. 


662 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


omy 


Fig.  189. — Eectal  Valve  after  Incision  bt  Mar- 
tin's Method  (Hemmeter). 


to  the  production  of  peristalsis  and  movements  of  the  bowels.  The 
author  therefore  believes  that  the  benefits  which  have  followed  valvot- 
are  due  in  many  cases  more  to  the  after-treatment  than  to  the 

mere  section  of  the  valves. 
The  permanency  of  the 
results,  however,  depends 
largely  upon  the  mainte- 
nance of  the  habits  which 
are  established  during  this 
period. 

Medicinal  Treatment. — It 
is  quite  the  habit  among  au- 
thors to  devote  long  para- 
graphs to  condemning  the 
use  of  laxative  medicines  in 
constipation,  and  immediate- 
ly follow  them  with  favorite 
formulas  for  pills,  powders, 
and  mineral  waters.  The 
fact  remains  that  whatever 
treatment  is  adopted  it  is 
necessary  occasionally  to  have  recourse  to  these  remedies.  The  danger 
consists  in  relying  upon  them  entirely  and  failing  to  treat  the  real 
cause  of  constipation.  A  wise  selection  of  these  useful  remedies  marks 
the  true  clinician.  One  should  study  the  condition  of  patients  and 
determine  those  forms  of  laxatives  which  seem  indicated  by  the  char- 
acter of  the  stool  and  the  general  symptoms.  "Where  the  stools  are 
too  dry  and  hard,  together  with  free  administration  of  water,  one  may 
give  some  saline,  such  as  sulphate  of  magnesia, 
sulphate  of  soda,  cream  of  tartar,  or  phosphate 
of  soda.  Common  salt  sometimes  acts  very 
well.  These  remedies  may  be  given  in  one  full 
dose  before  meals,  or  in  small  broken  doses 
during  the  day,  in  order  to  stimulate  the  secre- 
tion of  the  intestinal  glands.  They  may  also 
be  administered  in  the  form  of  laxative  waters, 
such  as  Eubinat,  Apenta,  Hunyadi,  Congress, 
Hathorn,  or  Friedrichshall.  Glycerin  is  an  ex- 
cellent remedy  in  this  ij^Q  of  constipation, 
and  may  be  given  in  doses  of  from  1  to  4 
drams  three  times  a  day.  When  there  is 
much  mucus  in  the  intestinal  canal,  cascara  sagrada  is  one  of  the 
best  laxatives;  in  fact,  it  is  the  most  generally  applicable  of  all  of 


Fig.  190. — Rectal  Valve  af- 
ter Operation  by  Pen- 
nington's Clip. 

simple  .atony    without 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        563 

them.  There  are  many  preparations  of  this  drug  upon  the  market, 
but  only,  three  of  them  need  he  given  any  serious  consideration. 
The  confections  and  aromatic  extracts  are  utterly  unreliable.  The 
powder,  fluid  extract,  and  cascarine  may  be  relied  upon.  The  fluid 
extract  is  best  given  either  pure  or  in  malt  preparations:  maltine 
and  maltzyme,  with  caseara,  2  to  6  drams,  at  bedtime,  or  from  1 
to  2  drams  after  each  meal.  The  fluid  extract  is  best  administered 
by  dropping  from  10  to  40  minims  in  a  half  tumbler  of  water  and 
allowing  this  to  stand  for  about  fifteen  minutes;  when  the  resinous 
constituents  of  the  extract  settle  to  the  bottom  of  the  glass,  the  clear 
part  of  the  solution  should  be  decanted  off;  this  contains  all  the  laxa- 
tive elements  of  the  drug,  and  is  generally  efficient  in  its  action.  The 
powder  is  given  in  doses  of  3  to  6  grains.  The  administration  of 
strychnine,  nux  vomica,  and  other  nerve  tonics  is  quite  important  along 
with  caseara  in  these  cases.  Confection  of  black  pepper  is  a  favorite 
remedy  with  some  of  the  English  surgeons,  especially  Dr.  Cripps.  It 
is  very  difficult  to  get  it  properly  made  in  this  country,  and  therefore 
it  is  little  used.  Franck's  "  grains  de  sante  "  are  often  very  useful  in 
simple  atonic  constipation.  Where  there  is  sallowness  of  the  skin  and 
jaundiced  conjunctiva  indicating  congestion  of  the  liver,  the  following 
triturate  tablets  may  be  given: 

^   Calomel gr.  |; 

Podophyllin gr.  y^g  ; 

Bicarbonate  of  soda gr.  1. 

Ft.  tab.  No.  1. 

Sig.:  Take  after  each  meal. 

One  of  the  best  combinations  for  a  temporary  laxative  effect  is  that 
known  as  Cathcart's  pill.    It  consists  of 

^  Ex.  eolocynth  eomp gr.  jss.; 

Aloin    gr.  i; 

Ex.  belladonna. 


.^  .  .        , aa  gr.  ±. 

Ex.  nuxis  vomica,  j 

Mi.  et  fiat  pil.  JSTo.  1. 

One  or  two  may  be  given  at  bedtime. 

Citrate  of  magnesia,  licorice  powder,  phosphate  of  soda,  and  the 
various  proprietary  laxatives  are  all  more  useful  for  cleansing  out 
the  bowel  and  treating  diarrhoea  than  they  are  for  constipation. 

In  old  people,  with  hearty  appetites,  the  old-fashioned  Lady  Webster 
pill  given  after  the  evening  meal  will  frequently  give  more  satisfac- 
tion than  any  other  remedy. 

Where  there  is  congestion  of  the  rectum  or  pelvic  organs,  cold- 


564  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

water  enemata  should  be  used  instead  of  laxatives  for  moving  the 
bowels.  The  use  of  glycerin  suppositories  for  this  purpose  is  very 
popular,  but  they  wall  produce  rectitis  if  continued  for  a  long  time. 
The  above  remedies  alternated  one  with  the  other  are  useful  adjuvants 
to  the  local  and  constitutional  treatment  of  constipation,  but  they  are 
simply  adjuvants  or  helps,  and  should  never  be  relied  upon  exclusively. 
Useful  as  all  such  remedies  are,  they  should  be  employed  only  for 
temporary  relief  while  the  actual  cause  of  the  constipation  is  being 
removed. 

Faecal  Impaction. — This  consists  in  an  arrest  of  the  fscal  mass 
at  some  portion  of  the  intestinal  canal;  it  usually  takes  place  at  the 
cfficum,  the  sigmoid  flexure,  or  in  the  ampulla  of  the  rectum.  It  may 
also  occur  in  sacculi  or  diverticuli  of  the  intestine. 

The  causes  are  similar  to  those  of  constipation.  Catarrhal  dis- 
eases and  dilatation  of  the  colon  very  frequently  produce  it,  as  do 
foreign  bodies  in  the  intestinal  canal,  such  as  fruit-pits,  grape-seeds, 
enteroliths,  and  cestodes.  The  faecal  mass  is  hard,  sticky,  and  ordi- 
narily contains  excessive  lime  salts;  it  is  made  up  of  small,  round 
lumps  compressed  together  by  the  muscular  action  of  the  bowels.  In 
those  cases  in  which  the  impaction  takes  place  at  the  caecum,  it  is 
often  assumed  that  the  mass  is  arrested  above  the  caecal  valve  in  the 
small  intestine,  but  this  is  not  frequently  the  case. 

Sijmpfoms. — The  symptoms  of  impaction  are  ordinarily  constipation 
or  the  sudden  cessation  of  faecal  movements,  followed  in  a  short  time 
by  griping,  heaviness  or  weight  in  the  region  of  the  impaction,  and  a 
tendency  to  diarrhoea,  with  frequent  teasing,  liquid  stools,  sometimes 
containing  small  quantities  of  mucus  and  blood;  with  these,  symptoms 
of  auto-intoxication  occur  in  the  form  of  furred  tongue,  bad  breath, 
torpor,  and  mental  derangements,  such  as  hallucination,  delusions,  and 
even  mania;  indigestion,  flatulence,  and  fsecal  vomiting  may  be  caused 
by  this  condition,  although  the  last  symptom  is  quite  rare.  The  diar- 
rhoea is  produced  by  the  irritation  of  the  intestine  by  the  arrested 
mass. 

Reference  has  been  made  to  2  cases  of  mental  derangement  due 
to  retention  of  faecal  material  in  the  intestine;  and  a  case  of  epileptoid 
convulsions  has  been  seen  by  the  author,  apparently  due  to  the  arrest 
of  a  mass  of  plum-stones  in  a  child's  sigmoid  flexure.  Nervous  de- 
rangements following  constipation,  rapidly  succeeded  by  a  diarrhoea, 
are  always  indicative  of  faecal  impaction.  In  children  one  always  sus- 
pects cestodes;  thus  in  a  child  eight  years  of  age  a  mass  of  lumbricoid 
worms  as  large  as  the  fist  entirely  obstructed  the  rectum  except  for 
the  passage  of  small  amounts  of  fluid  faeces  around  it.  A  frequent 
inclination  to  go  to  stool  with  the  passage  of  only  wind  or  very  small 


CONSTIPATION,  OBSTIPATION,  AND  F^CAL  IMPACTION        565 


quantities  of  fluid  matter,  aching  in  the  left  side,  back,  or  pelvis,  and 
shooting  down  the  left  leg,  constant  spasm  or  pain  about  the  anus,  and 
frequent  or  difficult  urination,  may  all  be  occasioned  by  impacted 
faeces.  Where  the  impaction  is  in  the  sigmoid  flexure  or  rectum  the 
diagnosis  is  comparatively  easy,  either  by  the  aid  of  the'  finger  or  by 
the  sigmoidoscope,  but  when  it  is  in  the  upper  portions 
of  the  colon  this  is  sometimes  very  difficult,  as  it  simu- 
lates volvulus,  intussusception,  and  intestinal  neoplasms. 

The  length  of  time  an  impaction  may  exist  is  indefi- 
nite; in  1  case  it  lasted  from  the  end  of  May  until  the 
middle  of  September.  In  another  case  in  which  the  au- 
thor was  consulted  in  August,  1899,  with  regard  to  the 
nature  of  a  tumor  about  the  size  of  a  baseball  in  the  right 
iliac  fossa,  and  supposed  at  the  time  to  be  a  tumor  of 
the  caecum,  the  woman  stated  that  the  lump  had  been 
there  for  over  a  year  and  had  caused  her  little  incon- 
venience; her  physician  testified  to  the  fact  that  it  had 
not  apparently  grown  in  three  months;  she  suffered  at 
the  time  from  tenesmus  and  frequent  small  fluid  passages 
which  brought  no  relief.  Under  the  use  of  large  colon 
flushings,  with  full  doses  of  sweet-oil  and  glycerin,  on 
the  fourth  day  the  mass  moved  into  the  transverse  colon, 
and  finally  passed  through  the  sigmoid  and  into  the  rectal 
ampulla,  where  it  was  arrested.  It  was  necessary  to  dilate 
the  sphincters  to  remove  it.  It  was  composed  of  faecal 
and  calcareous  material,  indurated,  but  smooth  on  its 
surface,  and  weighed  1  pound  and  3  ounces. 

The  diagnosis  has  been  already  discussed.  In  persons 
with  thin  abdominal  walls  the  doughy  feeling  of  the  mass 
sometimes  may  be  made  out.  Gersuny  claims  to  be  able 
to  distinguish  it  from  neoplasms  by  the  adherence  of  the 
mucous  membrane  to  the  mass,  but  this  seems  incredible. 
The  acuteness  of  the  attack  combined  with  the  general 
symptoms  above  detailed  are  more  reliable  guides. 

Treatment. — The  treatment  of  impaction  consists  in 
removing  the  impacted  mass.  Where  it  is  low  down  in 
the  rectum  and  its  passage  is  obstructed  by  spasm  of 
the  sphincter,  it  may  sometimes  be  necessary  to  stretch 
this  muscle  and  break  up  the  mass  by  a  scoop  (Fig.  191)  or  by 
Currier's  forceps.  The  use  of  such  instruments  in  the  rectum 
ordinarily  results  in  more  or  less  traumatism  to  the  anus,  and 
occasions  the  patient  considerable  suffering  afterward.  It  is  better 
before  resorting  to  them  to  administer  an  enema  of  a  half  pint  of 


Fig.  191.— Kel- 
set's  Eectal 
Scoop. 


566  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

warm  water  containing  2  drams  of  inspissated  ox-gall  or  2  ounces  of  hy- 
drogen peroxide;  this  should  be  retained  as  long  as  possible  and  repeated 
four  times  within  twenty-four  hours;  at  the  end  of  this  time  it  will 
usually  be  found  that  ordinary  fascal  impactions  of  the  rectum  will 
have  softened  down  so  that  the  patient  can  pass  them  without  assist- 
ance. Where  the  impaction  is  in  the  sigmoid  flexure  this  same  method 
should  be  employed,  except  that  the  injection  should  be  given  through 
a  long  Wales  bougie  and  with  the  patient  in  the  knee-chest  posture. 

Drastic  cathartics  should  never  be  given  in  impaction.  While  these 
drugs  increase  the  amount  of  fluid  in  the  intestine  and  thus  tend  in 
a  certain  way  to  soften  the  mass,  the  peristaltic  action  and  spasm 
which  they  produce  are  likely  to  result  in  traumatism  of  the  walls  of 
the  gut  from  pressure  against  the  mass,  and  may  sometimes  occasion 
rupture  where  the  intestine  is  already  thinned  and  inflamed.  They  may 
also  result  in  forcing  a  hard  faecal  mass  into  a  narrowed  or  strictured 
caliber  of  the  gut,  thus  bringing  on  complete  occlusion  and  all  the 
symptoms  and  consequences  of  obstruction. 

After  trying  the  injections  for  twenty-four  hours,  if  the  mass  is 
not  softened  and  does  not  move,  it  is  then  wise  to  attempt  its  removal 
by  mechanical  measures.  When  the  impaction  is  in  the  rectum,  it 
is  best  to  give  the  patient  gas  or  chloroform  and  dilate  the  sphincters. 
In  many  cases  the  mass  will  be  passed  spontaneously  as  soon  as  the 
patient  goes  under  the  influence  of  the  anaesthetic.  Where  the  patient 
is  unwilling  to  take  an  anaesthetic  it  is  best  to  introduce  a  bivalve 
speculum  into  the  rectum  and  through  this  try  to  break  down  the  mass 
by  the  use  of  forceps  and  scoop.  The  handle  of  an  ordinary  tablespoon, 
a  dull  uterine  curette,  and  bullet  forceps  may  take  the  place  of  Cur- 
rier's forceps  and  the  rectal  scoop.  In  women  the  mass  may  be  forced 
out  through  the  anus  or  held  by  two  fingers  introduced  into  the  vagina 
while  it  is  being  broken  up. 

When  the  impaction  occurs  in  the  sigmoid  flexure  it  is  almost 
impossible  to  reach  it  with  instruments.  Here  one  must  depend  very 
largely  upon  the  use  of  enemas  and  massage.  Impactions  may  be 
dislodged  by  the  use  of  the  pneumatic  proctoscope;  twenty-four  hours 
after  having  injected  glycerin  and  ox-gall  the  instrument  is  introduced 
and  the  sigmoid  flexure  distended  by  air,  thus  lifting  it  up  into  the 
pelvic  cavity  and  dislodging  the  mass.  This  procedure  has  succeeded 
in  3  obstinate  cases,  in  one  of  which  it  was  necessary  to  dilate  the 
sphincter  before  the  hard  mass  could  pass.  Where  such  procedures 
fail  one  would  be  justified  in  anaesthetizing  the  patient  and  introducing 
his  hand  through  the  rectum  and  into  the  sigmoid  flexure  in  order 
to  break  up  the  mass  and  remove  it;  this  should  not  be  done,  however, 
by  any  one  whose  hand  measures  more  than  7|  inches  in  circumference. 


CONSTIPATION,  OBSTIPATION,  AND   F^CAL   IMPACTION        567 

In  all  cases  before  dilating  the  sphincter  or  attempting  to  remove 
the  faecal  mass  by  the  introduction  of  the  hand,  a  large  injection  of 
warm  sweet-oil  should  be  given  to  lubricate  the  parts,  and  thus  make 
the  mass  move  smoothly  through  the  gut.  Where  the  impaction  occurs 
above  a  stricture  too  much  manipulation  from  below  should  be  avoided, 
as  the  gut  may  be  very  easily  ruptured  under  such  conditions.  One 
should  not  hesitate  under  these  circumstances  to  perform  an  inguinal 
colotomy,  and  in  this  way  relieve  the  patient.  If  the  stricture  is  a 
benign  one  it  may  be  treated  afterward  by  dilatation  or  resection  as 
the  surgeon  may  think  best;  but  neither  of  these  procedures  should 
be  undertaken  with  a  mass  of  impacted  faeces  arrested  above  the 
stricture. 

In  all  eases  in  which  impaction  has  esisted  for  any  length  of  time 
there  will  result  a  certain  amount  of  inflammation  of  the  mucous 
membrane  which  should  be  carefully  treated  after  the  removal  of  the 
impaction.  Immediately  following  the  removal,  the  colon  should  be 
flushed  with  a  large  quantity  of  hot  saline  solution  in  order  to  wash 
it  out  and  also  to  stimulate  the  patient,  as  great  esliaustion  frequently 
follows  the  removal  of  these  masses.  On  the  day  following  the  bowels 
should  be  moved  by  a  saline  laxative,  after  which  they  should  be  thor- 
oughly irrigated  with  normal  salt  solution  or  some  astringent,  such  as 
fluid  extract  of  krameria,  hydrastis,  or  pinus  canadensis.  Mathews 
advises  the  use  of  tincture  of  iron  or  tannin  in  solutions  with  glycerin 
in  such  cases.  The  objection  to  glycerin  is  that  it  ordinarily  produces 
such  a  prompt  movement  of  the  bowels  that  the  tannin  does  not  have 
the  astringent  effect  which  is  desired.  Strychnine  and  belladonna 
should  be  administered  to  promote  peristaltic  action  and  overcome 
the  atony  which  the  distention  produces.  As  soon  as  the  inflamed  con- 
dition of  the  parts  permits,  the  patient  should  be  required  to  take 
regular  exercise,  such  as  horseback-riding,  golf-playing,  walking,  etc., 
and  his  diet  should  be  carefully  arranged  in  order  to  prevent  the 
recurrence  of  impaction.  It  is  not  necessary  to  repeat  the  precautions 
heretofore  expressed  with  regard  to  the  regular  movements  of  the 
bowels  in  patients  who  have  once  suffered  from  impaction. 


CHAPTEE    XY 
PRURITUS    AS  J 

Prueitus  axi  is  a  symptom  and  not  a  disease.  It  is  associated 
with  or  caused  by  almost  every  known  disease  of  the  rectum  and  anus; 
it  is  also  produced  in  a  reflex  manner  by  affections  of  the  uro-genital 
organs  and  by  certain  constitutional  conditions,  such  as  gout,  rheuma- 
tism, and  lithffimia.  If,  however,  we  consider  it  simply  as  a  symptom 
or  complication  of  other  affections,  then  logically  it  should  be  treated 
of  under  those  diseases,  and  the  present  chapter  would  not  be  written. 
This,  however,  would  cause  confusion,  for  many  still  believe  in  a 
pruritus  ani  essentialis — a  disease  without  a  pathology,  an  effect  with- 
out a  cause. 

There  is,  according  to  dermatologists,  a  variety  of  pruritus  unas- 
sociated  with  any  pathological  changes  in  the  parts  where  the  itching 
is  felt,  and  which  is  due  to  some  central  neurosis.  This  condition 
is  usually  distributed  over  a  large  area  of  the  body,  although  it  may 
be  limited  to  some  distinct  spot.  It  is  often  associated  with  neuras- 
thenia, hysteria,  and  melancholia.  The  mind  seems  to  have  a  dis- 
tinct influence  upon  such  cases,  and  they  are  frequently  subjects  of 
delusions,  in  that  they  believe  they  find  pediculi  or  irritating  sub- 
stances upon  their  bodies.  Bronson  describes  this  condition  very 
well,  enumerating  three  forms  of  essential  pruritus:  pruritus  seni- 
lis, prurigo  (of  Hebra),  and  pruritus  hiemalis.  These  forms  of  pru- 
ritus, however,  do  not  affect  the  anus.  They  attack  the  extremities 
or  the  body  itself,  especially  the  thorax  and  abdomen.  In  classify- 
ing pruritus  ani,  he  says:  "It  is  often  due  to  irritations  originating 
from  the  rectum  or  regions  high  up,  or  possibly  from  a  strictured 
urethra,  but  it  is  much  more  apt  to  be  associated  with  those  general 
conditions  mentioned  above.  The  appearance  of  the  anus  in  this  affec- 
tion is  characteristic.  It  has  a  whitish,  sodden  look  that  is  usually 
accompanied  with  a  foul-smelling  secretion.  The  folds  are  swollen 
and  the  furrows  deepened.  Often  the  effect  of  scratching  is  to  compli- 
cate it  with  eczema.  It  is  one  of  the  most  distressing  forms  of  the 
disease."  This  statement  is  in  keeping  with  that  of  a  large  number 
568 


PRURITUS  ANI  569 

of  dermatologists,  surgeons,  and  writers  upon  rectal  diseases.  It  will 
be  observed,  however,  that  he  describes  pathological  changes  in  the 
appearance,  structures,  and  secretions  of  the  anus.  Thus  tacitly  he 
proves  that  there  is  an  etiological  agent  for  the  itching  in  these  condi- 
tions. The  very  changes  which  he  describes  here  as  existing  in  cases 
of  pruritus  essentialis  are  the  products  of  established  diseases  of  the 
rectum  and  anus. 

Allingham  (loc.  cit.,  p.  349)  insists  upon  pruritus  always  being  due 
to  some  pathological  or  functional  cause.  He  does  not  limit  it  to  some 
simple  local  changes,  conditions,  or  diseases  about  the  margin  of  the 
anus,  but  attributes  it  to  constitutional  and  general  conditions.  It  is 
this  latter  class,  in  which  no  local  affection  or  alteration  of  the  parts 
is  observable,  that  has  led  the  dermatologists  and  writers  on  this  subject 
to  elaborate  this  doctrine  of  essential  pruritus  ani.  Mathews  takes 
the  stand  that  it  is  always  a  disease  of  local  origin,  and  he  explains 
the  fact  that  we  fail  sometimes  to  find  alterations  or  accidents  sufficient 
to  account  for  the  symptoms  upon  the  basis  of  reflex  action,  arguing 
that  the  inferior  hsemorrhoidal  nerves  are  distributed  to  the  lower 
inch  (or  more)  of  the  mucous  membrane  of  the  rectum,  as  well  as  to 
the  external  surfaces  around  the  anus;  and  that  whatever  irritates 
these  nerve-ends  will  also  produce  irritation  and  itching  about  the 
anus.  This  asserts  that  those  cases  of  pruritus  in  which  no  external 
cause  of  the  symptom  can  be  found  are  due  to  some  cause  inside  of 
the  sphincter  and  involving  the  lower  inch  of  the  rectum. 

All  of  this  is  true,  but  there  are  still  found  cases  in  which  no 
disease  can  be  located  either  in  the  anus  or  in  the  lower  inch  of  the 
rectum.  Shall  these  instances  be  called  pruritus  ani  essentialis?  By 
no  means,  because,  as  will  be  seen  later  on,  there  are  several  condi- 
tions, both  constitutional  and  local,  which  produce  pruritus  and  yet 
cause  no  pathological  changes  in  the  lower  portion  of  the  rectum  or  anus. 
There  is  no  such  thing  as  pruritus  ani  essentialis,  strictly  understood; 
but,  on  the  contrary,  every  case  of  pruritus,  however  mild  or  severe,  will 
find  a  cause  in  some  local  or  general  functional  or  pathological  change. 

Pruritus  ani  is  a  condition  characterized  by  many  eccentricities. 
To  the  student  of  rectal  diseases  it  is  simply  a  symptom  referable 
to  sundry  pathological  conditions,  but  to  the  patient  it  means  an  agony 
beside  which  pain  woiild  be  a  pleasure.  Its  marked  feature  is  itching 
about  the  anus,  but  this  itching  is  different  from  that  felt  in  any 
other  part  of  the  body:  it  comes  when  at  repose,  it  is  not  relieved  by 
scratching,  and  is  out  of  all  proportion  to  the  changes  in  the  parts. 
It  is  also  peculiar  in  that  hypersesthetic,  hysterical  individuals  rarely 
suffer  from  it,  and  if  they  do  they  suffer  less  than  phlegmatic,  strong 
individuals.     Cases  of  dyssesthesia  or  hyposelaphesia,  whose  sensibility 


570 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


to  pain  is  below  normal,  are  the  greatest  sufferers  from  pruritus  ani. 
It  is  also  peculiar  in  that  time  does  not  palliate  it.  The  longer  it  lasts 
the  worse  it  gets. 

Characteristics. — The  characteristic  feature  of  this  affection  can  be 
described  in  one  word — itching:  remittent  at  times,  but  when  it  has 
once  begun,  incessant,  tormenting,  tantalizing,  distracting.  Almost 
every  adjective  in  the  English  language  expressive  of  irritation,  dis- 
comfort, and  pain  has  been  applied  to  this  sensation.  As  to  when 
or  how  it  begins,  few  patients  can  give  any  satisfactory  account.  They 
all  know  that  for  a  long  time  they  have  felt  a  sensation  of  uneasiness, 
or  rather  a  slight  inclination  to  scratch  about  the  anus;  but  they  can 
only  fix  the  time  when  this  sensation  changed  from  that  of  semi- 
pleasure  to  the  maddening,  unrelievable  affliction  which  is  termed 
pruritus  ani.  In  some  the  itching  appears  only  at  night  after  the 
patient  has  retired  and  becomes  thoroughly  warm  in  bed;  in  some  it 
occurs  whenever  they  experience  a  sudden  change  from  cold  to  heat; 
in  some  the  attacks  are  not  influenced  by  cold  or  heat,  by  night  or 
day,  but  they  are  brought  on  by  mental  strain,  overwork,  and  anxiety; 

in  some  a  change  of  diet  or  a 
special  article  of  food  will  ex- 
cite the  most  violent  attacks;  in 
others  removal  from  one  cli- 
mate to  another,  such  as  from 
the  seashore  to  the  mountains, 
or  inland  to  the  seashore,  will 
induce  the  affection.  Under 
whatever  circumstances  or  from 
whatever  causes  the  condition 
arises,  it  is  never  described  as 
anything  else  but  an  itcliing — 
intolerable,  painful,  and  mind- 
racking. 

After  the  condition  has  ex- 
isted for  some  time,  nervous 
and  physical  phenomena  begin 
to  appear  as  a  result  of  the  irri- 
tation and  exhaustion  due  to 
loss  of  rest  and  sleep.  Fre- 
quently the  cart  is  put  before  the  horse,  and  these  conditions  are 
diagnosed  as  the  predominant  element  in  the  case,  and  assigned  as 
the  cause  of  pruritus  instead  of  vice  versa.  Pruritus  ani  is  not  a  frequent 
symptom  of  nervous  exhaustion,  but  nervous  exhaustion  is  a  frequent 
result  of  pruritus  ani.    Small  scratches,  denuded  spots  about  the  margin 


Fig.  192. — Pruritus  Ani. 


PRURITUS  ANI  571 

of  the  anus,  thickened  and  cedematous  folds  (Fig.  192),  the  disappear- 
ance of  the  normal  pavement  epithelium  about  the  margin  of  the  anus, 
a  white  and  sodden  appearance  of  the  epidermis  of  this  region  associated 
with  a  moist  and  foul-smelling  secretion;  or,  on  the  other  hand,  a  dry 
and  brittle  condition  of  the  mucous  membrane,  which  cracks  when  it  is 
pulled  apart  or  distended  by  large  fsecal  masses,  all  of  these  conditions 
have  been  described  as  symptoms  of  pruritus.  They  do  exist  with  the 
pruritus,  but  like  it  they  are  the  symptoms  and  results  of  the  same 
pathological  conditions. 

Etiology. — The  sources  to  which  pruritus  has  been  attributed  are 
without  number.  Almost  every  affliction  to  which  the  human  flesh 
is  heir  has  been  assigned  as  a  cause  of  pruritus.  Many  of  these  are 
without  any  foundation  in  fact,  but  have  been  lighted  upon  by  searchers 
for  something  to  account  for  the  itching  with  which  their  patients 
suffered.     The  causes  are  external,  internal,  constitutional,  and  reflex. 

External  Causes. — By  these  one  understands  those  affections  or 
diseases  which  are  located  upon  and  affect  entirely  the  external  anal 
surfaces.  Under  this  class  may  be  enumerated  pediculi,  parasites, 
eczema,  dermatitis,  herpes,  and  erythema.  The  forms  of  pediculi 
which  may  affect  the  anus  are  the  pediculi  pubis  and  corporis;  in  fact, 
neither  of  these  very  frequently  locates  itself  about  the  anus.  The 
spores  are  not  often  found  in  this  region,  and  the  itching  of  the  anus 
which  is  associated  with  their  presence  upon  the  body  is  generally 
reflex.  JSTevertheless  where  they  have  been  found  upon  the  body  and 
an  itching  about  the  anus  is  complained  of,  one  should  carefully  search 
the  parts  for  their  presence,  and  whether  they  are  found  or  not,  use 
those  remedies  which  are  known  to  destroy  their  spores,  such  as  blue 
ointment,  fluid  extract  of  larkspur,  and  solutions  of  mercuric  chloride. 

Of  the  visible  parasites  which  cause  itching  about  the  anus,  the 
trichophyton  is  about  the  only  one  of  any  importance.  This  parasite, 
which  is  the  cause  of  eczema  marginatum,  is  not  infrequently  found 
upon  the  nates  and  about  the  anus.  The  fungus  was  discovered  by 
Bazin  in  1854,  and  it  is  said  to  be  identical  with  the  parasite  found 
in  tinea  tonsurans  and  tinea  sycosis.  It  is  found  in  the  superficial 
layers  of  the  epidermis,  is  said  to  be  highly  contagious,  and  may  be 
transmitted  from  animals  to  men.  Some  patients  are  very  susceptible 
to  this  disease,  and  when  pruritus  exists  in  men  who  have  the  care 
of  horses  or  cows,  it  is  always  well  to  take  this  condition  into  consid- 
eration. The  diagnosis  is  described  in  books  on  dermatology,  but  it  may 
be  said  that  a  microscopic  examination  will  always  disclose  it  if  present; 
a  small  scraping  of  the  epidermis  obtained  from  one  of  the  little 
hypersemic  areas  should  be  placed  upon  a  slide,  treated  with  diluted 
liquor  potassge,  and  then  covered  with  a  glass  cover  and  subjected  to 


572  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

some  pressure.  The  characteristic  appearance  of  the  fungus  is  that 
it  contains  very  numerous  spores  or  rather  mycelia.  The  spores  exceed 
the  mycelia,  and  they  are  more  numerous  in  the  corneous  layer  and 
around  the  bulbous  roots  of  the  hair.  Failure  to  discover  the  mycelia 
should  not,  however,  be  taken  as  a  positive  proof  of  their  absence; 
repeated  negative  examinations  are  necessary  to  be  conclusive.  When 
they  have  been  discovered  the  disease  should  be  treated  in  the  same 
manner  as  elsewhere  in  the  body.  Sulphur  in  the  form  of  an  ointment, 
or  sodium  hyposulphite  (1  dram  to  the  ounce),  either  as  a  lotion  or  in 
the  form  of  an  ointment,  will  generally  prove  efficacious.  Sulphuric 
acid  and  chrysarobin  ointment  are  also  very  effectual  in  inveterate 
cases.     Salicylic  acid  combined  with  ichthyol  is  also  satisfactory. 

True  eczema  of  the  erythematous  form  sometimes  occurs  about  the 
anus.  One  is  very  likely  to  mistake  it  for  the  erythema  produced  by 
the  local  irritations  of  vaginal  discharges,  and  harsh  or  irritating  de- 
tergent materials.  This  form  of  eczema  is  characterized  by  more  or 
less  extensive  red  and  whitish  patches;  there  are  no  fissures,  papules, 
or  pustules,  but  there  may  be  some  excoriated  points  and  raw  spots 
due  to  scratching;  it  is  an  exceedingly  rare  affection  of  the  anus,  and 
there  is  really  no  means  to  make  a  positive  diagnosis  between  it  and 
some  other  forms  of  true  erythema  due  to  such  irritations  as  have 
been  mentioned  above. 

Herpes  is  another  local  affection  which  sometimes  occurs  about  the 
margin  of  the  anus,  and  is  said  to  produce  pruritus,  but  it  more  fre- 
quently produces  actual  pain  than  itching.  When  it  exists,  it  is  per- 
fectly evident  to  the  naked  eye,  and  there  is  no  difficulty  in  its  diag- 
nosis. Its  treatment  has  been  already  described.  It  should  be  remem- 
bered, however,  that  where  herpes  occurs  upon  the  muco-cutaneous 
margins  there  is  always  reason  to  suspect  malarial  complications. 

Local  Causes. — Itching  may  be  associated  with  or  a  symptom  of 
fissure,  piles,  fistula,  ulceration,  diseases  of  the  crypts,  foreign  bodies, 
constipation,  catarrhal  diseases,  cestodes,  neoplasms  of  the  rectum, 
gonorrhoea,  and  syphilis;  but  that  aggravated  cases  of  true  pruritus 
are  ever  due  entirely  to  these  causes  is  very  doubtful.  Fissures  and 
fistulas  may  be  cured,  haemorrhoids  removed,  ulcerations  healed  by 
local  applications,  and  yet  the  itching  for  which  these  operations  were 
done  persists  sometimes  in  a  more  aggravated  form,  so  that  one  loses 
faith  in  these  conditions  as  causes  of  the  symptom.  It  is  only  neces- 
sary to  say  here  that  wherever  these  diseases  exist  in  patients  who 
suffer  from  pruritus  ani,  they  should  be  removed  by  operation  or  what- 
ever treatment  is  necessary;  but  at  the  same  time  one  should  be  exceed- 
ingly guarded  in  promises  to  the  patient  with  regard  to  the  effect  of 
such  proceeding  upon  the  pruritus,  as  it  may  or  may  not  be  benefited. 


PRURITUS  ANI  573 

Diseases  of  the  crypts  of  Morgagni  are  frequently  the  source  of 
considerable  irritation  around  the  margin  of  the  anus.  This  irritation 
may  not  amount  to  a  pain,  but  cause  more  or  less  itching  of  a  char- 
acter distinct  from  that  known  as  pruritus.  It  is  made  worse  by 
faecal  passages,  and  is  not  affected  by  heat  or  cold;  neither  does  it 
come  on  at  night  after  the  patient  is  comfortably  covered  and  pre- 
pared for  sleep.  Foreign  bodies  in  the  rectum,  if  they  be  small  and 
not  cutting  or  pointed,  may  produce  a  certain  amount  of  itching,  but, 
as  will  be  seen  in  the  chapter  upon  this  subject,  the  symptoms  occa- 
sioned by  these  bodies  are  entirely  different  from  those  known  as 
pruritus.  If,  however,  threadworms  and  lumbricoids  are  considered 
as  foreign  bodies,  an  exception  may  be  made  to  this  rule;  some  of  the 
most  exaggerated  cases  of  pruritus  ani  are  due  to  the  presence  of  these 
in  the  rectum.  The  diagnosis  and  methods  of  search  for  these  little 
parasites  are  described  elsewhere,  but  no  case  of  pruritus  should  ever 
be  prescribed  for  until  they  have  been  thoroughly  eliminated  as  an 
etiological  factor.  Constipation  is  considered  by  many  authors  as  a 
frequent  cause  of  pruritus  ani.  Here,  again,  a  symptom  is  discussed 
as  a  disease;  constipation,  as  generally  understood,  is  not  a  disease  in 
itself,  but  a  cbndition  brought  about  by  a  variety  of  affections,  and 
it  may  be  said  to  be  frequently  the  result  of  the  same  class  of  patho- 
logical conditions  which  produce  pruritus;  it  is  a  complication  but  not 
a  cause  of  pruritus. 

Tumors  of  the  rectum  may  cause  a  certain  amount  of  itching  about 
the  anus,  but,  as  a  rule,  they  produce  entirely  different  symptoms,  such 
as  heaviness,  weight,  dull  aching  pain,  and  tenesmus.  Catarrhal  dis- 
eases of  the  rectum  and  anus  are  among  the  most  frequent  causes; 
whether  it  be  the  atrophic  or  hypertrophic  form,  pruritus  is  one  of 
the  commonest  symptoms.  The  dry,  brittle  condition  of  the  muco- 
cutaneous membrane  about  the  anus,  described  as  a  symptom  of  pru- 
ritus ani,  is  nothing  more  or  less  than  a  part  of  atrophic  catarrh  of 
the  rectum  and  anus;  and  that  moist,  sodden,  whitish  condition  seen 
in  chronic  cases  of  this  condition  are  the  results  of  the  hypertrophic 
type. 

Gonorrhoea  of  the  rectum  may  be  looked  upon  as  a  specific  form  of 
catarrhal  disease  of  the  rectum.  It  is  said  to  produce  pruritus  ani, 
but  in  a  number  of  cases  of  undoubted  gonorrhoea  of  the  rectum  seen 
by  the  author  not  one  of  them  has  suffered  from  any  unusual  itching, 
much  less  the  typical  form  of  it,  as  considered  in  this  chapter.  Terti- 
ary and  hereditary  syphilis  may  be  the  cause  of  pruritus,  in  that  it 
sometimes  produces  a  condition  similar  to  that  caused  by  atrophic 
catarrh,  viz.,  a  very  brittle,  dry  mucous  membrane,  always  easily  torn 
and  becoming  irritated  upon  the  least  provocation. 


574  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

Constitutional  Causes. — Digestive  derangements,  improper  dietary, 
rheumatism,  gout,  uricaniiia,  diabetes,  and  hepatitis  may  all  be  the 
causes  of  pruritus  ani.  ]\Iany  patients  who  are  subject  to  periodical 
attacks  of  pruritus  ani  go  for  weeks  or  months  without  suffering  in 
the  least,  when  suddenly,  after  some  derangement  of  the  digestive 
functions,  especially  the  development  of  an  acid  or  fermentative  process 
in  the  intestinal  canal,  the  symptoms  are  lighted  up  and  continue  until 
these  functional  conditions  are  readjusted. 

Certain  articles  of  food  or  drink,  especially  shell-fish,  strawberries, 
and  highly  seasoned  condiments  are  all  productive  of  attacks  in  indi- 
viduals predisposed  to  pruritus  ani.  Overindulgence  in  the  use  of 
tobacco  may  also  produce  it.  In  some  persons  any  condition  or  indis- 
cretion which  causes  a  congestion  of  the  liver  is  very  likely  to  light 
up  an  attack. 

The  constitutional  conditions  which  produce  pruritus  ani  most  fre- 
quently are  rheumatism,  gout,  and  uricasmia.  The  pathology  and  etiol- 
ogy of  gout  are  so  obscure  and  little  known  that  one  hesitates  to  speak 
positively  concerning  it,  but  undoubtedly  it  and  pruritus  are  frequently 
associated  in  the  same  individuals,  and  remedies  which  relieve  the 
attacks  of  gout  also  relieve  the  pruritus.  Rheumatism  and  uricsemia, 
if  not  identical,  are  intimately  associated  in  the  human  economy;  gas- 
tro-intestinal  fermentation  is  an  important  element  in  both.  It  is 
often  difficult  to  distinguish  between  the  rheumatic  and  lithic-acid 
diathesis.  If  any  one  will  examine  carefully  a  given  number  of  patients 
suffering  from  pruritus,  he  will  elicit  the  fact  that  a  large  percentage 
of  them  have  suffered  more  or  less  from  rheumatism  or  uricfemia;  the 
urine  is  nearly  always  extremely  acid  or  loaded  with  urates,  and  the 
itching  is  almost  invariably  exacerbated  or  relieved  by  an  increase 
or  decrease  of  these  phenomena.  Excess  in  diet  and  drink,  or  any- 
thing which  produces  an  increase  of  uric  acid  in  the  system,  or  of 
intestinal  fermentation,  is  likely  to  bring  on  an  attack  of  pruritus,  and 
when  the  constitutional  condition  has  once  been  relieved  the  pruritus 
just  as  promptly  subsides.  Sweet  wines,  champagne,  pastry,  and  an 
excess  of  carbohydrate  foods  will  bring  on  attacks  of  congestion  and 
itching  about  the  anus  in  individuals  predisposed  to  uricsemia. 

There  is  strong  evidence  in  favor  of  the  theory  that  muscular 
rheumatism  is  produced  by  intestinal  fermentation  and  excess  of  uric 
acid  in  the  system,  and  it  is  certain  that  cases  predisposed  to  muscular 
and  subacute  rheumatism  are  very  frequently  the  victims  of  pruritus 
ani.  When  they  begin  to  suffer  from  vague  muscular  pains,  it  is  always 
a  warning  to  them  that  the  fires  of  pruritus  are  soon  to  be  lighted 
up,  and  just  as  soon  as  the  rheumatic  symptoms  subside  the  others 
are  extinguished. 


PRURITUS  ANI  575 

Idiosyncrasies  with  regard  to  diet  are  always  to  be  remembered  in 
studying  cases  of  pruritus  ani;  in  one  case  an  attack  was  always  caused 
by  drinking  a  cup  of  Java  coffee,  though  the  patient  could  indulge 
reasonably  in  almost  every  other  variety  of  this  beverage.  Another 
was  exempt  from  this  disorder  except  during  the  strawberry  season; 
with  him  indulgence  in  this  fruit  was  always  paid  for  by  an  attack 
of  pruritus  ani.  Sea-food,  salt  meats,  and  certain  fruits  affect  other 
patients  in  the  same  manner.  These  all  act  through  disturbances 
in  the  digestive  tract,  and  thus  prove  the  constitutional  origin  of 
pruritus. 

Reflex  Causes. — Urethral  stricture  or  inflammation,  phimosis,  en- 
larged prostate,  stone  in  the  bladder,  pregnancy,  uterine  diseases,  or 
gall-stones  may  produce   pruritus   ani. 

It  is  also  caused  by  irritating  discharges  from  the  vagina,  such 
as  leucorrhcea,  gonorrhoea,  and  the  watery  secretions  from  malignant 
disease.  The  condition  also  often  follows  the  establishment  of  men- 
struation or  the  menopause.  One  should,  therefore,  in  searching  for 
the  cause  of  pruritus,  carefully  eliminate  all  such  affections  before 
coming  to  a  conclusion  in  regard  to  the  etiology  of  the  condition. 

Treatment. — In  the  whole  range  of  medical  science  there  is  no 
disease  for  which  so  many  and  various  specifics  have  been  recommended 
as  for  this;  there  is  hardly  a  drug  in  the  whole  materia  medica,  or  a 
procedure  in  the  surgery  of  the  rectum,  that  has  not  at  some  time 
been  advised  and  applied  for  the  relief  of  this  condition.  The  proof 
of  the  real  suffering  produced  by  pruritus  ani  is  confirmed  by  the 
inconvenience  and  torture  which  these  patients  are  willing  to  un- 
dergo in  order  to  be  rid  of  it.  It  would  require  a  volume  to  describe 
the  various  nostrums,  simple  and  complicated,  which  have  been  vaunted 
as  "  sure  reliefs  for  itching  piles  and  pruritus."  As  pruritus  is  not  in 
itself  a  disease,  but  only  a  symptom  of  some  other  pathological  condi- 
tion, the  treatment  will  resolve  itself  into  the  management  of  that 
condition,  and  efforts  directed  toward  the  relief  of  itching  while  the 
pathological  condition  is  being  cured.  If  there  be  hsemorrhoids, 
fistula,  fissure,  condylomata,  stricture,  or  other  pathological  con- 
ditions about  the  anus  which  apparently  demand  operative  inter- 
ference, it  should  be  undertaken  at  once,  but  always  with  a  very 
careful  prognosis  so  far  as  the  relief  of  pruritus  is  concerned.  The 
methods  of  procedure  in  such  cases  are  fully  described  in  their  appro- 
priate place  and  need  not  be  repeated  here.  Where  foreign  bodies  exist 
in  the  rectum,  whether  they  be  organic  or  inorganic,  their  removal 
will,  of  course,  be  necessary.  The  methods  of  treating  intestinal  para- 
sites are  described  in  books  on  general  medicine,  but  one  simple  remedy 
seems  so  often  overlooked  that  the  writer  feels  called  upon  to  call 


676  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

attention  to  it.  Lime-water  injected  into  the  rectum  and  drunk  freely 
will  invariably  destroy  threadworms  in  a  very  short  time.  From  4 
to  6  ounces  should  be  injected  twice  a  day,  and  as  much  should  be 
drunk  four  or  five  times  daily. 

When  evidences  of  reflex  irritation  are  present,  the  attention  of 
the  surgeon  should  be  directed  to  the  removal  of  their  cause.  Thorough 
and  persistent  dilatation  of  the  urethral  strictures,  the  crushing  or 
removal  of  stone  in  the  bladder,  the  radical  and  proper  treatment  of 
uterine  diseases,  and  the  surgical  treatment  of  gall-stones  should  all 
be  promptly  and  thoroughly  carried  out.  It  will  often  happen,  how- 
ever, that  these  procedures  are  insufficient  to  eradicate  the  pruritus 
ani,  and  one  will  come  back  to  the  old  conclusion  that  it  is  due  more 
to  general  conditions  than  to  local  or  reflex  irritations.  As  to  rheu- 
matic, uricaemic,  and  gouty  cases,  it  is  unnecessary  to  go  into  any 
elaborate  description  of  their  treatment.  Nitrogenous  diet,  composed 
of  meat,  eggs,  fish,  leguminous  and  non-starchy  vegetables,  associated 
with  alkaline  diuretics,  such  as  lithia,  citrate  of  potash,  and  benzoate 
of  soda,  together  with  some  form  of  salicylic  compound,  will  compose 
the  general  regimen.  Some  cases  can  not  take  salicylic  acid  or  salicylate 
of  soda,  and  yet  their  stomachs  bear  salophen,  salol,  or  salipyrine  quite 
well.    In  gouty  and  uriceemic  diatheses  piperazine  acts  remarkably  well. 

The  habits  and  diet  of  these  patients  should  be  generally  altered. 
In  those  cases  in  which  pruritus  is  associated  with  excessive  energy, 
athletic  dissipation,  or  overwork,  these  habits  should  be  suppressed 
and  a  more  quiet  life  enjoined.  In  phlegmatic  individuals,  where 
there  is  a  tendency  to  overeating,  drinking,  indulgence  in  tobacco 
and  other  stimulants,  such  practices  should  be  curtailed,  and  moderate, 
regular  exercise  insisted  upon.  When  the  bowels  are  constipated  they 
should  be  properly  regulated.  If  the  stools  are  hard  and  lumpy, 
enemata  of  oil  should  be  given  to  prevent  irritation  and  traumatism 
of  the  margin  of  the  anus.  If  possible,  these  patients  should  sleep 
between  two  linen  sheets,  the  bed-covering  should  be  as  light  as  is  com- 
patible with  comfort,  the  room  should  be  well  ventilated  and  without 
any  artificial  heat. 

In  those  cases  due  to  catarrhal  conditions  of  the  bowel,  and  the 
number  is  large,  the  catarrh  should  be  treated  as  indicated  in  the 
chapter  upon  that  subject.  One  thing,  however,  may  be  mentioned, 
and  that  is  the  fact  that  the  passage  of  a  cold  rectal  tube  through 
the  anus  once  or  twice  a  day  sometimes  gives  these  patients  the  most 
unexpected  relief;  whether  this  is  brought  about  by  dislodging  some 
small  foreign  body,  or  whether  by  a  stimulating  effect  upon  the  cir- 
culation about  the  anus,  or  by  its  reflex  influence  (as  some  have  claimed 
for  the  steel  sound  in  urethral  itching),  it  is  impossible  to  say.     Where 


PRUKITUS  AXI  577 

there  is  an  excoriation  of  tlie  mucous  membrane  inside  of  the  sphincter, 
the  application  of  pure  ichthyol,  or  sometimes  a  10-per-eent  solution 
of  argonin,  will  give  rapid  and  effectual  relief  and  hasten  the  restora- 
tion of  the  parts  to  their  normal  condition. 

In  the  pruritus  of  liver  diseases  pilocarpine  in  small  doses  some- 
times acts  almost  as  a  specific;  it  should  he  given  in  triturate  tablets 
(gV- tV  grain)  by  the  mouth. 

Five  grains  of  ichthyol  three  times  a  day  is  said  to  be  very  useful 
in  those  cases  due  to  the  menopause,  hut  the  writer  has  had  no  experi- 
ence with  it.  Bromide  of  soda  has  given  better  results  than  any  other 
remedy  in  the  reflex  types  of  pruritus.  In  the  large  majority  of  cases, 
however,  regulation  of  the  bowels,  nitrogenous  diet,  intestinal  anti- 
ferments,  and  some  form  of  salicylates  will  comprise  the  general 
treatment. 

Local  Treatment. — Local  applications  are  the  sheet-anchors  during 
the  processes  of  removing  the  pathological  conditions-  accountable  for 
pruritus;  by  them  it  is  possible  to  relieve  the  patient's  distress,  quiet 
the  nervous  condition,  obtain  the  rest  and  sleep  so  necessary  to  the 
restoration  of  general  physical  tone,  and  to  retain  his  confidence  during 
a  sometimes  tedious  and  prolonged  treatment  necessary  for  the  eradica- 
tion of  etiological  factors.  One  of  the  several  means  of  relief  for 
pruritus,  and  one  which  should  be  employed  before  any  other  applica- 
tion is  made,  is  hot  water;  the  patient  should  be  instructed  to  apply 
to  the  anus  sponges  dipped  in  water  as  hot  as  he  can  bear  for  five 
or  ten  minutes  before  retiring.  If  the  itching  recurs  in  the  night,  this 
process  should  be  repeated  before  making  any  other  local  application. 
This  will  sometimes  entirely  relieve  the  symptoms  and  enable  the 
patient  to  obtain  a  comparatively  comfortable  night's  rest.  In  the 
majority  of  cases,  however,  something  more  will  be  necessary. 

One  of  the  simplest  local  applications  is  blackwash,  which  has 
been  used  for  many  years  as  an  application  for  pruritus,  and  by  many 
physicians  is  still  considered  the  best  and  most  reliable  remedy.  It 
should  be  applied  after  bathing  with  hot  water.  Carbolic  acid  in  some 
combination  is  probably  the  most  universally  applicable  of  all  drugs 
for  the  relief  of  the  itching;  it  may  be  applied  in  ointments,  or  solu- 
tions in  water  of  from  5  to  20  per  cent.  An  excellent  combination  of 
this  drug  with  salicylic  acid  is: 

]^  Ac.  carbolici oij; 

Ac.  salicylici oj; 

Glycerins  §j. 

M.  sec.  art. 

Sig.:  Apply  to  the  parts  by  camel's-hair  brush  or  cotton  swab  after 
hathing  in  hot  water. 
37 


578  THE  AXUS,  RECTUM,  AND   PEL^HC  COLON 

The  solution  should  be  perfectly  clear.  A  milky  cloudiness  impairs 
its  usefulness,  but  a  reddish  tinge  does  not.  It  may  be  repeated  sev- 
eral times  during  the  night,  but  it  is  very  rare  that  two  applications 
will  not  secure  a  good  night's  rest,  especially  if  the  rectum  is  cleaned 
out  by  a  cold-water  enema  before  retiring. 

Mathews  (loc.  cit.,  p.  499)  recommends: 

I^   Campho-phenique    3J; 

Aquffi  dest oj- 

M.  This  should  be  applied  as  a  lotion  after  the  use  of  hot  water, 
repeating  it  frequently  if  necessary;  this  application  is  occasionally 
very  effectual  but  often  disappointing. 

Chloral  hydrate  in  the  strength  of  10  to  30  grains  to  the  ounce 
of  glycerin  and  water  sometimes  affords  almost  instant  and  prolonged 
relief;  and  yet  there  are  cases  in  which  it  makes  the  itching  worse. 
An  ointment  composed  of  ichthyol  10  parts,  boric  acid  5  parts,  and 
lanolin  85  parts  will  be  found  to  act  exceedingly  well,  especially  in 
those  cases  in  which  there  is  an  erythematous  or  eezematous  condition 
about  the  margin  of  the  anus.  Diachylon  ointment  is  also  useful  in 
these  cases.  The  following  formula  laid  down  by  Adler  in  a  recent 
paper  before  the  American  Proctologic  Society  is  an  excellent  combina- 
tion and  well  worthy  of  a  trial  in  obstinate  cases: 

]^  Fid.  ext.  hamamelis  f5J; 

Fid.  ext.  ergot fBij; 

Fid.  ext.  hydrastis foj; 

Comp.  tine,  benzoin foij; 

Carbolized  olive-  or  linseed-oil,  )  »- . 

Carbolic  acid  5  per  cent,  j 

Shake  well  before  using. 

Carson  recommends  1  dram  of  powdered  camphor  to  1  ounce  of 
lard  as  a  specific  in  pruritus  ani,  but  experience  with  it  has  not  been 
favorable;  sometimes  the  suffering  was  intensified  rather  than  relieved. 

"Waugh  commends  xery  highly  the  following  formula: 

^  Benzoini  pulv oj; 

Hydrarg.  animon oss.; 

Lanolini oJ. 

Sig.:  Apply  twice  a  dav,  avoiding  coffee,  alcohol,  and  sweets. 

In  cases  where  there  are  fissure-like  cracks  in  the  mucous  mem- 
brane due  to  atrophic  catarrh  or  specific  affections,  the  following  pre- 
scription, recommended  by  Cripps  (p.  278),  has  given  great  relief: 


PRURITUS  ANI  579 

^  Ex.  conii 3j; 

Olei  ricini 3j; 

Lanolini oj. 

Nitrate  of  silver  in  solutions  of  from  2  to  35  per  cent  is  often  a 
very  useful  application  for  the  relief  of  itching.  If  applied  too  often, 
however,  it  may  produce  inflammation  or  even  sloughing  of  the  super- 
ficial skin.  In  a  certain  number  of  patients  oily  preparations,  such  as 
ointments,  seem  to  aggravate  the  symptoms;  in  such  cases  washes  of 
one  kind  or  another  may  give  relief.  The  following  formula,  recom- 
mended by  AUingham,  is  one  of  the  best  of  these: 

^  Liq.  carbonis  detergens,  ]  __   «r^. 

Wright's  glycerinse,  i    ^^' 

Pulv.  zinci  oxid.,  ] 

^1      .  y aa  3iv; 

Caiamis  prep.,        j 

Pulv.  sulphuri  prep oss.; 

Aquge   ad.  f o^j. 

Sig.:  Paint  over  the  parts  once  or  twice  a  day. 

Where  there  is  much  thickening  of  the  perianal  tissues  the  fol- 
lowing is  said  to  be  very  useful: 

^  Liq.  potassse,  "j 

01.  cadini,       V aa  §j. 

Alcohol,  ] 

Sig. :  Eub  into  the  parts  once  a  day  and  follow  it  by  a  soothing  oint- 
ment, such  as: 

3^  Ung.  zinci  ox 5jj 

Chloroform 3]. 

Sig. :  Apply  freely  to  the  parts  and  allow  the  chloroform  to  evaporate 
before  covering  with  dressings. 

Where  there  is  a  tendency  to  too  great  moisture  about  the  anus, 
some  sort  of  desiccating  powder  should  be  used  during  the  day  to 
keep  the  parts  dry  and  prevent  chafing.  Oxide  of  zinc  and  calomel 
in  equal  parts,  or  aristol  10  parts  with  stearate  of  zinc  90  parts,  are 
very  soothing  and  healing  in  this  condition.  Bismuth,  boric  acid, 
resinol,  calamine,  and  talcum  powders  are  also  useful  for  this  pur- 
pose.    The  following  formula  is  highly  recommended: 

^  Listol oij; 

Ac.  borici oj^ 

Talcum  purificat - oJ- 

Sig.:  Dust  freely  over  the  parts  three  or  four  times  a  day. 


580  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

Where  the  parts  are  dry  and  fissured,  as  in  eczematous  or  atropine 
catarrhal  conditions,  it  is  sometimes  possible  to  obtain  great  relief  by 
painting  them  with  flexible  collodion.  One  per  cent  of  ichthyol  mixed 
with  this  is  advisable  in  cases  where  there  is  much  thickening  of  the  skin. 

Ten  grains  of  methylene  blue  in  an  ounce  of  collodion,  or  in  aqueous 
solution  in  obstinate  cases,  will  be  found  very  satisfactory.  The  aqueous 
solution  is  preferable  when  there  is  much  moisture  about  the  parts. 

In  2  cases  in  which  the  parts  were  irritated  and  tender  orthoform 
gave  immediate  relief. 

With  all  these  applications  the  parts  should  be  protected  from 
rubbing  on  each  other  by  pledgets  of  cotton  or  gauze.  The  fact  is 
that  one  is  often  compelled  to  run  the  whole  gamut  of  local  applica- 
tions before  the  particular  one  is  found  which  gives  the  individual 
patient  most  relief.  Every  case  of  pruritus  ani  is  a  problem  in  itself, 
and  if  by  chance  or  good  judgment  the  practitioner  selects  at  his  first 
visit  a  remedy  which  will  relieve  his  patient  from  the  tormenting  symp- 
tom, he  will  have  established  his  professional  reputation  in  that  quarter 
at  once  and  secured  a  faithful  as  well  as  grateful  patron.  There  are 
cases,  however,  reported  by  reliable  authors,  in  which  all  these  local 
applications  and  constitutional  treatments  have  been  ineffectual  to 
relieve  the  intolerable  itching. 

Before  the  disease  was  treated  upon  a  constitutional  basis  many 
such  cases  were  seen,  and  occasionally  the  most  heroic  measures  were 
employed  for  their  relief.  A  strong  galvanic  current  has  been  applied 
to  the  parts,  both  through  sponges  and  wire  brushes,  but  it  can  not 
be  said  that  any  radical  relief  was  ever  obtained  by  it.  In  one  or  two 
instances  the  itching  was  relieved  by  the  application  of  the  actual 
cautery  at  white  heat. 

Mathews,  in  a  report  to  the  American  Proctologic  Society,  has 
recounted  some  cases  in  which  he  had  failed  by  all  methods  of  local 
application  to  relieve  the  symptoms,  and  finally  resorted  to  the  removal 
of  the  superficial  skin  for  about  1  inch  around  the  anal  margin.  The 
writer  has  done  this  operation  once,  not  as  a  matter  of  necessity  but 
as  an  experiment  for  the  relief  of  pruritus  ani.  Undoubtedly  it  relieved 
the  symptom,  but  the  protracted  healing  of  the  parts,  the  suffering, 
and  the  subsequent  contraction  of  the  anus  indicated  that  the  proce- 
dure is  only  justifiable  in  the  most  desperate  cases,  and  then  only  after 
a  thorough  understanding  by  the  patient  of  its  nature  and  what  it 
entails. 

One  other  method  deserves  to  be  mentioned,  and  that  is  deep  and 
persistent  pressure  upon  the  parts.  AUingham  first  discovered  that 
pressure  over  the  anus  would  relieve  the  sensation  of  pruritus,  and 
advised  the  introduction  of  a  specially  formed  plug  into  the  anus  at 


PRURITUS  ANI  581 

bedtime,  and  keeping  it  there  by  a  bandage  throughout  the  night.  This 
has  been  tried  with  success  at  times,  but  the  results  have  more  fre- 
quently been  disappointing. 

The  X-ray  and  high  frequency  current  are  now  being  used  very 
extensively  in  the  treatment  of  pruritus.  The  author  has  seen  great 
benefit  follow  the  use  of  the  ray  in  a  few  cases  where  the  usual  remedies 
had  failed.  The  number  has  not  been  sufficiently  large,  however,  to 
classify  them  and  thus  indicate  the  exact  type  in  which  it  is  likely  to 
prove  beneficial,  but  it  appears  worthy  of  trial  in  obstinate  cases.  Great 
care  should  be  exercised  in  its  use,  however,  lest  too  long  seances  or  too 
strong  rays  result  in  burns  which  will  make  the  condition  practically 
incurable.  As  to  the  high  frequency  currents  the  writer  has  had  no 
experience;  but  excellent  results  from  its  use  have  been  reported  by 
Piffard,  Denoyes  and  others  (Les  Courants  de  Haute  Frequence,  p.  263). 

In  conclusion,  it  may  be  said  that  if  catarrhal,  constitutional,  and 
digestive  diseases  are  recognized  and  treated  as  the  causes  of  pruritus, 
there  will  be  little  difficulty  in  the  management  of  these  cases.  The 
itching  can  be  controlled  in  a  large  majority  of  cases  by  the  application 
of  the  carbolic  and  salicylic  mixture,  and  although  the  conditions  which 
originate  the  pruritus  may  recur  after  having  been  once  cured  and  the 
pruritus  with  them,  the  same  management  and  treatment  will  effect  their 
relief. 


CHAPTER   XYI 
HEMORRHOIDS— PILES 

Before  the  history  of  medicine  began  a  knowledge  of  haemorrhoids 
existed.  In  Egypt  there  were  "  pile  doctors  "  before  Joseph  was  sold 
into  bondage.  "  The  Lord  will  smite  thee  with  the  botch  of  Egypt, 
and  with  the  emerods  "  (Dent,  xxviii,  27),  is  the  threat  of  Moses  against 
an  impatient  and  a  rebellious  people.  "  And  he  smote  the  men  of  the 
city,  both  small  and  great,  and  they  had  emerods  in  their  secret  parts  " 
(I  Sam.  y,  9),  "  And  he  smote  his  enemies  in  the  hinder  parts:  he 
put  them  to  a  perpetual  reproach "  (Psa.  Ixxyiii,  QQt),  are  quotations 
from  Holy  Writ  descriptiye  of  the  aflBictions  of  the  Philistines  for 
their  desecration  of  the  ark  of  God,  and  indicate  the  views  of  an- 
tiquity concerninig  a  disease  most  prevalent  among  the  civilized  na- 
tions of  to-day. 

The  term  Jicemorrhoids,  according  to  its  derivation,  signifies  a  flow 
of  blood,  a  haemorrhage.  It  is  not  altogether  appropriate  in  the  sense 
in  which  it  is  used,  for  frequently  the  disease  exists  without  any  bleed- 
ing whatcA'Cr.  It  has  also  been  applied  to  various  conditions.  For 
instance,  we  read  of  "  urethral  haemorrhoids,"  which  are  simply  papil- 
lomas; "  uterine  hgemorrhoids,"  a  roughened  and  congested  state  of 
the  OS  uteri  resembling  the  mucous  surface  of  an  internal  rectal  hsemor- 
rhoid  (Simpson);  and  "vesical  hemorrhoids,"  a  varicose  condition  of 
the  mucous  membrane  about  the  neck  of  the  bladder.  By  common 
consent,  however,  the  word,  when  found  in  general  literature  and  un- 
qualified by  any  other  term,  means  some  hypertrophy  or  varicosity  of 
the  vessels  at  the  lower  end  of  the  rectum. 

The  term  Piles,  which  means  a  swelling  or  tumor,  and  is  always 
applied  to  the  rectum,  is  more  correct.  For  some  unknown  reason 
the  latter  has  become  a  sort  of  vulgar  expression,  and  is  not  frequently 
employed  at  the  present  day,  but  in  this  work  the  two  will  be  used 
interchangeably. 

Definition. — Haemorrhoids  or  piles  are  tumors  chiefly  composed  of 
dilated  blood-vessels  or  blood-clots  situated  beneath  the  mucous  mem- 
brane or  muco-cutaneous  tissue  of  the  anus  or  rectum.  There  may 
582 


HEMORRHOIDS— PILES  583 

be  constant  or  periodic  bleeding  or  there  may  be  none;  there  may  or 
may  not  be  pain,  protrusion,  and  difficulty  in  defecation;  the  tumors 
may  be  entirely  outside  of  the  rectum,  they  may  be  inside,  or  they 
may  be  both  inside  and  outside. 

The  cardinal  features  are,  a  dilatation  of  the  veins,  a  swelling,  and 
an  increase  in  the  connective-tissue  stroma  by  which  the  convoluted 
vessels  are  supported. 

ETIOLOGY 

For  a  disease  which  has  been  known  so  long,  studied  so  much, 
and  so  thoroughly  written  about,  it  seems  strange  that  no  very  defi- 
nite and  accepted  theor}^  as  to  its  cause  has  been  accepted.  There 
is  scarcely  a  condition  or  disease  that  has  not  at  one  time  or  an- 
other been  said  to  produce  it.  Its  causes  are  both  predisposing  and 
exciting. 

Predisposing  Causes. — Age. — The  disease  is  found  at  all  ages.  The 
cases  found  in  infancy  are  comparatively  rare,  and  yet  they  are  indis- 
putable; Allingham  has  reported  a  case  of  venous  piles  in  a  child  three 
years  of  age.  In  the  summer  of  1892  the  author  exhibited  at  his 
clinic  two  children,  one  two  years  of  age  with  an  inflammatory  h^emor- 
rhoid,  the  other  between  two  and  three  years  having  well-developed 
internal  venous  hemorrhoids.  More  recently  he  has  seen  this  con- 
dition in  a  child  six  months  old.  Trunka  reported  39  children  below 
the  age  of  fifteen  years  who  were  affected  with  hsemorrhoids;  of  these, 
5  were  less  than  one  year  of  age. 

At  puberty  and  middle  age  haemorrhoids  are  very  frequently  mani- 
fested. This  is  explained  by  the  fact  that  the  environments,  habits, 
and  constitutional  conditions  at  these  ages  are  particularly  inclined 
to  bring  on  engorgements  of  the  hepatic  system  and  of  the  pelvic 
veins.  The  menstrual  periods  in  women,  the  development  and  exer- 
cise of  the  sexual  organs  in  both  men  and  women,  the  tendency  to 
overeating  and  to  dissipation,  child-bearing  and  childbirth,  muscular 
straining  in  exercise  or  labor,  and  the  constitutional  diseases  which 
are  prone  to  attack  at  this  period  of  life,  all  conduce  to  the  formation 
of  liEemorrhoids.  This  period  of  life,  therefore,  may  be  called  a  pre- 
disposing cause. 

As  the  patients  grow  older  many  of  these  influences  disappear,  but 
the  absorption  of  fat,  relaxation  of  the  muscles  around  the  rectum, 
constipation,  hardening  of  the  liver,  and  atheroma  of  the  blood-vessels 
contribute  to  the  causation  of  the  disease.  For  these  reasons  old 
age  may  be  considered  a  predisposing  cause. 

In  women  the  menopause  is  looked  upon  as  an  etiological  factor, 
because  a  periodic  loss  of  blood  ceases  and  the  hsemorrhoidal  flux  some- 


584  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

times  appears  as  a  sort  of  vicarious  menstruation.  The  theory  of 
change  of  life,  however,  hardly  sustains  this  doctrine. 

Age,  therefore,  may  be  said  to  be  a  predisposing  cause  only  insomuch 
as  it  affects  the  patient's  habits,  environments,  and  physical  conditions. 
The  disease  is  most  frequent  in  middle  life,  next  in  old  age,  and  least 
of  all  in  children. 

Sex. — The  majority  of  cases  of  hgemorrhoids  found  in  hospitals 
and  clinics  is  undoubtedly  among  males;  the  proportion  is  about  seven 
males  to  four  females.  This  preponderance  may  be  more  apparent 
than  real,  owing  to  the  fact  that  women  are  more  diffident  about  con- 
sulting physicians  for  rectal  troubles  than  men,  and  being  accustomed 
to  the  loss  of  blood  at  menstrual  periods,  do  not  attach  so  much 
importance  to  it  as  do  men. 

There  are  some  reasons  why  women  should  be  more  frequently 
afflicted  with  haemorrhoids  than  men.  The  monthly  congestion  of  the 
pelvic  organs,  the  pressure  of  displaced  or  pregnant  uteri  upon  the 
rectum,  the  traumatisms  of  childbirth,  the  frequency  of  fibroids  and 
ovarian  tumors,  and  the  habitual  constipation  in  them,  all  tend  to 
cause  dilatation  and  hypertrophy  in  the  veins  and  produce  hasmor- 
rhoidal  disease.  On  the  other  hand,  men  are  more  given  to  muscular 
and  nervous  strain;  they  more  frequently  indulge  in  overeating  and 
dlrinking;  they  are  more  often  the  victims  of  intemperance  and  excess- 
ive venery,  and  from  these  causes,  no  doubt,  the  disease  arises.  Stric- 
ture of  the  urethra  and  stone,  which  are  more  frequent  in  males,  may 
also  predispose  to  the  disease  in  this  sex. 

The  causes  which  predispose  women  to  hemorrhoids  are  somewhat 
balanced  by  the  monthly  menstrual  flow.  This  theory  is  borne  out 
by  the  fact  that  they  suffer  very  much  more  frequently  from  haemor- 
rhoids during  periods  of  menstrual  suspension,  gestation,  and  after 
the  menopause,  than  at  other  times.  Bodenhamer  states  that  it  is  no 
unusual  thing  to  observe  them  at  each  recurring  menstrual  period, 
both  conditions  coming  on  and  subsiding  together;  and  that  he  has 
seen  many  cases  in  which  the  menses  ceased  for  several  months  and 
the  patient  had  regular  periodical  bleeding  from  haemorrhoids  during 
this  period.  This  compensating  action  between  menstruation  and 
haemorrhoidal  bleeding  may  account  for  the  disparity  between  the  two 
sexes  in  this  disease. 

Occupations,  Habits,  and  Environments. — These  have  a  strong  pre- 
disposing influence  in  the  causation  of  haemorrhoids.  The  reason  why 
the  disease  is  so  rare  among  children  is  due  to  the  fact  that  their 
occupations  and  habits  are  regular  and  their  diet  is  uniform;  there  is 
no  nervous  or  muscular  strain,  and  therefore  no  cause  for  the  hsemor- 
rhoidal  condition  except  in  rare  instances. 


HEMORRHOIDS— PILES  585 

Those  occupations  which  require  severe  muscular  strain,  heavy 
lifting,  constant  standing  or  sitting  in  the  erect  posture,  are  very  likely 
to  bring  on  the  disease.  Eailroad  and  street-car  conductors,  truck- 
men, laborers,  and  miners  are  frequently  its  victims.  The  desk- 
worker  is  likely  to  become  sedentary  and  phlegmatic;  his  duties  con- 
duce to  constipation,  and  constant  bending  over  crowds  the  abdominal 
organs  down  upon  the  rectum,  thus  interfering  with  the  circulation 
and  predisposing  to  hemorrhoids. 

The  habits,  however,  have  much  more  to  do  with  the  production 
of  hgemorrhoids  than  occupation.  It  is  well  known  that  the  more 
civilized  nations  become,  the  more  frequently  are  they  affected  with 
this  disease.  Sedentary  habits,  excessive  eating,  indulgence  in  stimu- 
lants and  the  luxuries  and  comforts  which  are  enjoyed  by  the  higher 
classes,  all  tend  to  the  production  of  piles.  The  large  amounts  of 
rich  food  and  drink  consumed  by  this  class  surcharge  the  hepatic  cir- 
culation, and  sooner  or  later  bring  on  a  congestion  of  the  hsemorrhoidal 
veins  which  ends  in  haemorrhoids.  Good  living,  full  diet,  and  moderate 
drink  are  not  necessarily  productive  of  the  disease,  provided  enough 
active  exercise  is  taken  to  use  up  the  material  absorbed.  Frequently 
patients  live  to  a  good  old  age  amid  luxuries,  wealth,  and  self-indul- 
gence, never  experiencing  any  ha^morrhoidal  affection  until  they  give 
up  business  and  begin  to  lead  a  sedentary  life,  when  suddenly  the 
condition  appears.  The  superfluous  carbohydrates  are  not  utilized, 
they  congest  the  liver,  and  through  it  the  rectal  veins. 

It  seems  somewhat  contradictory  to  these  facts  to  find  the  disease 
as  frequently  in  thin,  ansemic,  temperate  individuals  as  in  the  plethoric; 
the  explanation  of  this  is  that  muscular  and  nervous  exhaustion  result 
in  general  relaxation  and  dilatation  of  the  venous  system,  and  conse- 
quently piles  develop. 

Heredity. — "  That  heredity  predisposes  to  haemorrhoids  is  a  fact 
established  beyond  all  doubt "  (Bodenhamer).  That  successive  genera- 
tions of  a  family  suffer  from  this  disease  is  explained  by  the  simi- 
larity of  environments,  habits,  and  constitutional  conditions.  Their 
diet,  methods  of  life,  and  vocations  are  very  much  alike  from  one  gen- 
eration to  another,  and  therefore  they  suffer  from  the  same  diseases. 
While  there  seems  to  be  some  hereditary  influence  in  the  disease, 
it  is  a  heredity  of  predisposing  causes  more  than  of  the  disease  itself; 
if  it  were  the  latter, '  children  would  be  frequently  born  with  these 
dilated  veins  and  hypertrophies  instead  of  developing  them  later 
in  life. 

Temperament. — Patients  suffering  from  hepatic  diseases  are  often 
the  subjects  of  hgemorrhoids.  It  is  well  known  that  melancholic, 
choleric,  sallow,  depressed  individuals  generally  suffer  from  some  dis- 


586  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

order  of  the  liver.  Temperament  is  not  the  cause  of  piles,  but  the 
same  pathological  condition  which  brings  about  one  also  causes  the 
other. 

Climate  and  Seasons. — These  have  undoubtedly  some  influence  in 
the  production  of  hc^morrhoids.  The  disease  is  comparatively  more 
frequent  in  the  very  hot  and  cold  than  in  the  temperate  zones.  The 
explanation  of  this  lies  in  the  fact  that  in  hot  climates  the  patient  is 
subject  to  congestion  of  the  liver  and  malarial  conditions,  together 
with  a  relaxation  produced  by  heat  and  lack  of  exercise.  In  the  cold 
climates  the  people  are  active,  subjected  to  muscular  straining,  and  on 
the  move  constantly  to  keep  themselves  warm;  besides  this,  they  use 
alcohol  and  much  external  clothing  to  protect  themselves  from  the  rigor 
of  the  weather;  hence,  the  difficulties  of  removing  the  clothing  and  of 
reaching  convenient  places  for  stool  engenders  a  carelessness  and 
irregularity  in  this  regard  productive  of  hsemorrhoidal  disease.  Here 
again  it  is  not  so  much  the  climate  (hot  or  cold)  as  the  habits  of 
the  individual. 

So  also  with  the  seasons.  In  the  spring  haemorrhoids  are  more  likely 
to  develop  than  at  other  times,  because  the  system  can  not  consume 
the  amount  of  hydrocarbons  in  hot  weather  that  it  does  in  cold,  and 
when  warm  weather  comes  on  suddenly  the  dietary  habits  can  not  be 
adjusted,  the  portal  circulation  becomes  congested,  and  haemorrhoids 
appear. 

That  hsemorrhoidal  disease  is  more  marked  and  frequent  in  those 
countries  in  which  there  are  frequent  and  sudden  changes  in  tempera- 
ture is  better  explained  by  these  facts  than  by  the  theory  that  the 
blood  is  suddenly  driven  from  the  surface  into  the  internal  organs  and 
veins,  thus  causing  piles.  In  the  many  cases  in  which  cold  packs  have 
been  used  for  various  conditions,  not  a  single  case  has  been  reported 
in  which  the  sudden  chilling  of  the  surface  has  caused  haemorrhoids; 
if  the  sudden  driving  in  of  the  surface  blood  would  cause  the  disease 
it  certainly  ought  to  be  seen  in  these  cases. 

Anatomical  Causes. — Man  is  the  only  animal  in  which  this  disease 
is  at  all  frequently  found;  occasionally  dogs  suffer  from  it,  but  it  is  usu- 
ally in  fat,  lazy  house  dogs  or  very  old  ones  that  take  no  exercise,  but 
lie  around,  eat  whenever  opportunity  offers,  and  are  always  constipated. 

The  one  essential  anatomical  feature  that  distinguishes  man  from 
other  animals  is  the  erect  posture.  He  is  always  upright  during  the 
larger  portion  of  the  twenty-four  hours,  and  as  the  weight  of  the  blood 
column  is  proportionate  to  its  height,  and  the  cardiac  force  must  be 
sufficient  to  lift  this  weight,  the  distending  force  that  is  exercised 
upon  the  veins  can  be  realized.  Valves  in  a  vein  relieve  the  disten- 
tion to  a  certain  extent  by  preventing  backward  pressure,  but  veins  of 


HEMORRHOIDS— PILES  587 

the  portal  system  have  no  valves;  they  are  practically  upright  in  all  posi- 
tions except  when  lying  down,  and  if  one  is  sitting  constantly  and 
leaning  forward  over  the  desk  or  sewing-machine,  the  abdominal  organs 
are  pressed  downward  and  backward  upon  them,  thus  causing  obstruc- 
tion to  the  blood  current. 

The  blood-vessels  of  the  rectum  puncture  the  walls  of  the  gut  about 
3  inches  above  the  anus,  passing  through  the  muscular  walls  in  little 
buttonhole-like  slits,  and  then  divide  into  numerous  branches  which 
are  distributed  to  the  lower  end  of  the  organ;  Allingham  claims  that 
these  little  slits  serve  the  purpose  of  valves  for  the  veins.  Verneuil, 
on  the  other  hand,  claims  that  they  act  as  obstructions  to  the  venous 
circulation,  and  whatever  produces  spasm  or  peristaltic  action  in  the 
muscles  causes  constriction  of  the  veins,  congestion,  and  hsemorrhoidal 
disease.  The  thickness  of  the  arterial  walls  protects  them  from  com- 
pression, and  thus  the  blood  supply  remains  constant  while  its  return 
flow  is  obstructed.  Verneuil's  view  is  much  more  rational,  because 
in  order  to  act  as  valves  these  muscles  would  have  to  be  in  a  constant 
state  of  tonic  contraction,  which  we  know  is  not  the  case.  Moreover, 
admitting  for  the  moment  that  they  do  act  as  such,  it  is  perfectly 
clear  that  there  would  be  but  one  valve  between  the  liver  and  the 
rectum,  which  would  be  very  ineffectual.  From  these  facts  it  appears 
that  the  constant  upright  position  of  the  human  race,  inducing  thereby 
a  constant  pressure  from  a  blood  column  of  14  inches  or  more  in  height, 
is  the  most  plausible  explanation  of  the  prevalence  of  hemorrhoidal 
disease  among  men.  The  weight  of  this  column  and  the  cardiac  force 
necessary  to  lift  it,  being  constantly  active,  it  is  not  at  all  surprising 
that  the  thin-walled  veins  of  the  rectum  are  frequently  varicosed. 

The  loose  attachment  of  the  mucous  membrane  of  the  rectum  to 
the  muscular  walls  leaves  cellular  spaces  between  the  two  in  which 
the  veins  can  be  stretched  in  length  and  dilated  in  caliber,  thus  forming 
the  convolutions  which  go  to  make  up  a  true  hgemorrhoid. 

Exciting  Causes. — Constipation. — The  passage  of  a  solid  faecal  mass 
along  the  intestinal  canal  distends  it  more  or  less,  and  thus  squeezes 
out  the  blood  which  is  in  its  veins.  In  the  sigmoid  flexure  and  colon 
the  arterial  and  venous  supply  proceeds  in  a  circular  course  around 
the  gut,  anastomosing  freely;  fgecal  passages  and  peristaltic  action  here 
simply  empty  the  blood-vessels  by  forcing  the  blood  out  of  the  veins 
in  the  proper  direction;  but  in  the  rectum,  where  the  blood-vessels 
run  up  and  down  and  are  very  superficial,  the  fsecal  mass  sliding  over 
the  mucous  membrane  presses  upon  and  strips  or  milks  them,  as  it 
were,  in  the  opposite  direction  to  the  venous  current,  thus  not  only 
obstructing  the  circulation,  but  also  by  backward  pressure  producing 
a  mechanical   strain  upon   the  veins   and   the   little   blood   pools  in 


588  THE   ANUS,  RECTUM,  AND  PELVIC  COLON 

which  they  originate.  This  is  probably  the  chief  exciting  cause  of 
the  disease. 

The  increased  amount  of  blood  in  the  parts  causes  hypertrophy  of 
the  connective  tissues,  new  capillaries  develop,  and  thus  the  hasmor- 
rhoidal  tumor  is  formed.  After  this  has  taken  place,  the  distention 
produced  by  straining,  or  the  passage  of  the  faecal  mass,  causes  rupture 
of  the  thin  vessel  walls,  and  there  results  what  is  known  as  bleeding 
piles.  It  is  not  traumatism  or  friction  by  the  fgecal  mass,  as  a  rule, 
but  distention  which  causes  haemorrhage  from  piles.  Not  only  does 
constipation  act  in  this  mechanical  manner,  but  it  also  produces  a  gen- 
eral congestion  of  the  rectum  in  which  the  haemorrhoidal  vessels  take 
part.  It  necessitates  straining  at  stool  and  resort  to  cathartics,  the 
habitual  and  injudicious  use  of  which  is  frequently  followed  by  the 
development  of  piles.     Especially  is  this  true  of  the  resinous  drugs. 

The  old  practice  of  attributing  every  disease  to  torpidity  of  the 
liver  and  bowels,  and  beginning  all  treatment  with  a  large  dose  of 
calomel,  salts  and  senna,  gamboge,  or  aloes  has  frequently  resulted  in 
attacks  of  haemorrhoids  in  patients  who  had  no  knowledge  of  their 
previous  existence.  Warm  injections  are  also  productive  of  haemor- 
rhoidal disease  by  causing  an  excessive  flow  of  blood  to  the  parts  and 
frequently  failing  to  induce  an  active  movement  which  would  relieve 
this. 

Drugs. — In  addition  to  the  resinous  cathartics  other  drugs  are 
known  to  be  productive  of  haemorrhoids.  Such  substances  as  apiol, 
cantharides,  aloes  and  myrrh,  and  savin,  all  act  by  producing  congestion 
of  the  pelvic  veins,  more  or  less  increased  peristalsis,  and  consequent 
distention  of  the  hemorrhoidal  vessels.  Many  hsemorrhoidal  fluxes, 
called  vicarious  menstruation,  are  only  the  result  of  such  drugs. 

Diet. — Certain  articles  of  food  are  active  causes  in  haemorrhoidal 
attacks.  Substances  which  irritate  the  mucous  membrane,  excite  peri- 
stalsis, spasm  of  the  sphincters,  and  bearing-down,  are  very  likely  to 
induce  them.  Such  articles  as  aromatic  spices,  peppers,  mustard, 
highly  seasoned  sauces,  radishes,  water-cress,  tamales,  and  pickles  will 
frequently  bring  on  or  aggravate  piles. 

Bodenhamer  claims  that  the  habitual  use  of  oatmeal  is  very  effective 
as  an  exciting  cause,  but  the  author  is  not  able  to  confirm  this  state- 
ment. Wines,  malt  or  alcoholic  liquors  add  largely  to  the  mass  of  fluid 
in  the  veins,  produce  congestion  of  the  liver,  and  along  with  this  a 
similar  condition  in  the  rectal  veins  which  results  in  haemorrhoids. 
Tea,  when  used  to  excess,  may  produce  haemorrhoids  by  its  constipating 
effects,  but  coffee  very  rarely  does  so. 

Idiosyncrasies  with  regard  to  diet  occasionally  lead  to  the  develop- 
ment of  haemorrhoids  from  the  simplest  articles  of  food.     What  will 


HEMORRHOIDS— PILES  589 

induce  a  haemorrhoidal  attack  in  one,  hundreds  of  others  may  use  with 
impunity.  As  a  rule,  too  many  carbohydrates  induce  the  disease,  and 
foods  containing  excessive  amounts  of  refuse  material  do  so  through 
the  large  hard  stools  which  they  produce.  Such  lines  of  diet,  while 
advantageous  in  certain  conditions,  are  deleterious  in  patients  predis- 
posed to  hsemorrhoidal  disease. 

Strain. — Thrombotic  haemorrhoids  are  nearly  always  the  result  of 
muscular  strain.  They  may  occur  from  lifting  heavy  weights,  from 
a  misstep  or  fall  with  efforts  to  recover  one's  balance,  from  bicycling, 
dancing,  sweeping,  or  various  forms  of  muscular  strain.  All  efforts 
that  require  forcible  action  of  the  abdominal  muscles  are  associated 
with  action  of  the  pelvic  and  anal  ones  in  order  to  counteract  the 
downward  pressure  of  the  intestines  in  the  pelvis.  This  muscular  strain 
from  above  and  below  causes  pressure  upon  and  distention  of  the 
vessels  of  the  rectum,  and  may  cause  their  dilatation  or  rupture.  In 
the  latter  case  blood  is  poured  out  into  the  cellular  tissues,  where  it 
finally  clots  and  forms  a  thrombotic  hsemorrhoid. 

Straining  or  long  sitting  at  stool  are  very  frequent  causes  of  the 
disease  among  city  people  where  the  toilet-rooms  are  luxurious.  Men 
who  take  their  pipes  and  morning  papers  to  the  closet  with  them, 
acquire  the  habit  of  sitting  there  and  straining  in  a  position  in  which 
all  support  is  removed  from  the  veins.  This  habit  persisted  in  from 
day  to  day  unquestionably  brings  on  varicose  external  haemorrhoids, 
and  has  more  or  less  influence  in  the  production  of  the  internal  variety. 
The  same  effect  is  produced  by  habitually  sitting  upon  a  rubber  ring. 
The  buttocks  are  pulled  apart,  the  anus  drops  down,  there  is  no  ex- 
ternal support  from  the  folds  of  the  buttocks  or  from  pressure  upon 
the  seat,  the  veins  consequently  become  distended,  and  haemorrhoids 
ensue. 

Clothing. — Constrictions  about  the  waist,  especially  tight  bands  for 
supporting  the  trousers,  or  undue  lacing,  the  wearing  of  heavy  skirts 
supported  by  the  hips,  all  have  their  effect  in  aggravating,  if  not  in  pro- 
ducing, hsemorrhoidal  disease. 

External  Causes. — Whatever  causes  congestion  about  the  rectum  or 
anus  may  act  as  an  exciting  cause  of  hemorrhoidal  disease.  Wounds, 
injuries  or  contusions,  the  use  of  rough  and  irritating  detergent  sub- 
stances, such  as  newspaper,  corn-cobs,  etc.,  the  presence  of  foreign 
bodies,  threadworms,  and  other  larvae  inside  the  anus,  or  pediculi  and 
parasites  upon  the  external  surface,  may  all  produce  the  disease. 

Other  Diseases. — Hsemorrhoids  may  be  a  complication  or  the  result 
of  other  pathological  conditions  in  the  rectum  or  intestines.  Ulcera- 
tion or  stricture  of  the  intestine  or  urethra  may  result  in  this  disease, 
either  through  the  congestion  which  it  produces  or  the  straining  neces- 


590  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

sary  for  micturition  or  defecation.  With  regard  to  stricture  of  the 
rectum  as  a  cause  of  haemorrhoids,  the  fact  may  be  recalled  that  the 
most  usual  site  for  strictures  is  just  about  the  point  where  the  arteries 
and  veins  penetrate  the  muscular  wall  of  the  gut;  any  inflammatory 
condition  about  this  region  results  in  a  constriction,  due  first  to  spasm 
of  the  muscles,  and  secondly  to  the  deposit  of  lymph  and  fibrous  tissue 
which  obstructs  the  circulation.  Such  obstruction  always  affects  the 
veins  more  than  the  arteries,  because  the  walls  of  the  latter  are  stiffer 
and  do  not  yield  so  readily  to  the  pressure;  in  the  veins  there  is  no 
constant  pulsation  to  prevent  the  constriction,  but  simply  a  steady, 
gentle  flow,  and  little  by  little  they  become  encroached  upon  until  they 
may  be  almost  occluded  by  the  same  processes  which  the  artery  has 
been  able  to  resist.  Thus,  the  vein  being  constricted  and  the  artery 
still  pouring  blood  into  the  haemorrhoidal  area,  the  force  finally  falls 
upon  the  venous  walls,  causing  distention,  hypertrophy,  and  devel- 
opment of  hsemorrhoidal  tumors.  Generally,  however,  in  strictures 
of  the  rectum  the  haemorrhoidal  complication  is  a  matter  of  such  small 
moment  compared  with  the  etiological  cause  that  little  attention  is 
paid  to  it;  this  is  a  proper  view  of  the  situation,  because  the  cure  of 
haemorrhoids  would  be  of  no  benefit  to  the  patient  if  a  progressive  stric- 
ture is  left  to  take  its  course. 

Other  uterine  and  genito-urinary  diseases,  such  as  retroversion, 
anteversion,  procidentia,  cystitis,  prostatitis,  urethritis,  etc.,  may  bring 
on  attacks  of  piles,  but  the  latter  generally  subside  as  soon  as  the 
cause  is  removed. 

Diseases  of  the  heart,  liver,  and  kidneys  must  also  be  taken  into 
account  in  a  study  of  the  causes  of  haemorrhoids.  Valvular  insufficiency 
of  the  right  side  of  the  heart  no  doubt  has  some  influence  in  producing 
piles  through  the  backward  pressure  and  congestion  which  it  causes 
in  the  liver,  and  feeble  cardiac  action  induces  them  through  sheer 
lack  of  force  to  drive  the  stagnating  blood  through  the  vessels. 

Congestion  or  cirrhosis  of  the  liver  by  obstruction  to  the  portal 
circulation  increases  backward  pressure  in  the  hemorrhoidal  veins, 
causing  their  distention  and  the  development  of  haemorrhoids.  In  this 
class  of  cases  haemorrhage  from  the  tumors  is  very  frequent  and  no 
doubt  often  salutary.  Where  the  liver  is  surcharged  with  blood,  some 
overflow  is  beneficial,  and  these  bleedings  act  as  spontaneous  venesec- 
tions. Those  who  suffer  from  hepatic  disease  and  haemorrhoids  often 
feel  buoyant  and  comfortable  after  a  marked  hsemorrhoidal  flux,  and 
when  this  does  not  occur  every  three  or  four  days  they  become  morose, 
depressed,  and  suffer  from  digestive  troubles;  some  patients  of  this 
kind,  in  whom  operations  have  checked  the  haemorrhages,  grow  worse, 
develop  anasarca,  and  die  very  soon.     Some  of  the  older  surgeons,  ob- 


HEMORRHOIDS— PILES  591 

serving  this,  suggested  methods  for  the  reestablishment  of  the  haemor- 
rhoidal  flow.  It  is  wise,  therefore,  in  these  conditions  to  allow  the 
periodic  bleedings  to  continue  so  long  as  they  do  not  immediately  en- 
danger life,  and  confine  ourselves  in  treatment  to  those  methods  which 
prevent  inflammation  and  avoid  strangulation. 

In  acute  congestion  of  the  kidneys  and  lungs  haemorrhoids  and 
hsemorrhage  therefrom  may  occur.  If  a  sufficient  quantity  of  blood 
were  lost  in  the  incipiency  of  these  diseases,  it  might  be  of  some 
temporary  advantage  to  the  patient,  or  even  abort  the  disease,  but 
after  this  time  any  loss  of  the  vital  fluid  is  a  serious  complication. 
The  occurrence  of  piles  is  easily  explained  in  lung  affections,  but 
between  them  and  diseases  of  the  kidneys  it  is  difficult  to  make  out 
any  etiological  relationship. 

Certain  diseases  of  the  spinal  cord  appear  to  have  some  causative 
influence  in  the  production  of  hgemorrhoids.-  They  are  likely  to  occur 
in  patients  who  suffer  from  lateral  and  posterior  sclerosis  and  who 
are  markedly  constipated.  Peristaltic  action  is  almost  always  deficient, 
and  the  accumulation  of  faecal  masses  in  the  bowels  and  rectum  is  a 
very  constant  accompaniment  of  the  spinal  disease.  It  may  be  in  this 
indirect  method,  or  through  their  influence  upon  the  walls  of  the 
vessels,  that  these  diseases  act,  but  in  some  way  they  certainly  appear 
to  have  an  etiological  influence  in  the  production  of  haemorrhoidal 
diseases. 

In  acute  catarrh  of  the  rectum  there  is  a  congestion,  and  a  certain 
amount  of  dilatation  of  the  haemorrhoidal  vessels,  which  results  in  capil- 
lary haemorrhoids.  This  inflammatory  process,  however,  is  diffuse,  and 
consequently  fails  to  produce  those  localized  dilatations  and  congestions 
which  characterize  the  true  haemorrhoidal  disease. 

Chronic  atrophic  catarrh,  however,  may  produce  it.  The  inflamma- 
tion rarely  proceeds  lower  than  the  mucous  membrane  itself.  There 
is  no  submucous  deposit  constricting  the  blood-vessels  and  obstructing 
the  circulation,  but  there  is  atrophy  of  the  follicles,  deficiency  in  the 
mucous  secretions,  increased  friction  in  the  passage  of  the  faecal  masses, 
accumulation  of  these  masses  in  the  rectum,  and  a  generally  consti- 
pated condition,  all  of  which  tend  to  the  production  of  piles. 

In  the  hypertrophic  form  these  conditions  are  reversed,  and  conse- 
quently in  this  disease  haemorrhoids  are  seldom  seen  unless  they  have 
existed  previous  to  the  development  of  the  catarrhal  process.  Unfor- 
tunately the  haemorrhoids  are  frequently  mistaken  for  the  chief  cause 
of  offense  in  patients  who  suffer  from  these  conditions,  and  operations 
for  their  relief  signally  fail  to  cure. 

Emotions. — The  effect  of  the  emotions  in  the  production  of  haemor- 
rhoids has  been  referred  to  by  many  authors.     Grief,  fear,  anxiety,  and 


592  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

nervous  strain  have  all  been  known  to  bring  on  attacks.  No  satis- 
factory explanation  has  yet  been  given  of  this  fact. 

It  seems  probable  that  in  the  majority  of  instances  the  piles  existed 
before  the  emotional  disturbance  took  place,  and  that  through  some 
sudden  cardiac  activity  or  relaxation  of  the  sphincter  muscles  pro- 
trusion and  haemorrhage  have  been  brought  on.  A  hemorrhoidal  tumor 
is  not  simply  a  dilated  vein,  hut  an  aggregation  of  varicose  vessels 
held  together  by  a  network  of  connective  tissue;  it  is  impossible  to  sup- 
pose that  it  can  be  produced  in  an  instant  by  any  excitement.  Throm- 
botic piles  may  be  so  produced,  but  true  venous  haemorrhoids  can  not. 
This  fact  is  important  in  its  bearing  upon  suits  for  damages  in  rail- 
road and  other  accidents. 

Spasm  and  Atony  of  the  Sphincter  Muscles. — The  condition  of  the 
sphincter  muscles  has  sometimes  been  referred  to  as  an  etiological 
factor  in  the  production  of  hfemorrhoids.  One  can  understand  how- 
atony  of  the  sphincter  would  allow  more  room  for  dilatation  and  hyper- 
trophy in  the  lower  end  of  the  rectum  by  the  removal  of  its  support 
from  the  vessels;  but  how  spasm  of  the  sphincter  can  act  as  an  etio- 
logical factor,  except  in  cases  where  there  is  a  prolapse  of  the  mucous 
membrane  of  the  rectum,  is  difficult  to  comprehend.  Undoubtedly 
such  a  spasm  will  produce  a  strangury,  swelling  and  increased  inflam- 
mation in  a  prolapsing  hsemorrhoid,  but  it  does  not  produce  the  pile. 
Where  a  fold  of  mucous  membrane  prolapses  through  a  spasmodic 
sphincter,  it  may  be  caught  and  its  circulation  be  so  obstructed  that 
the  veins  become  dilated,  the  parts  hypertrophied,  and  a  hsemorrhoid 
may  result,  but  such  a  condition  is  very  rare. 

In  conclusion,  one  may  enumerate  the  etiological  factors  in  the 
production  of  haemorrhoids  in  the  order  of  their  importance  as  fol- 
lows: Erect  posture,  constipation,  improper  diet,  muscular  strain,  and 
diseases  of  the  liver,  spinal  cord,  genito-urinary  and  uterine  organs. 

Nomenclature. — In  literature  there  are  references  to  a  large  variety 
of  haemorrhoids  described  under  special  names,  which,  although  super- 
fluous, it  is  well  to  know.     They  are  as  follows: 

External  Hemorrhoids. — Those  located  at  the  margin  of  the  anus 
entirely  outside  of  the  rectum. 

Internal,  Blind,  or  Occult  Haemorrhoids,  Ha^morrhois  Cceca. — Those 
seated  above  the  muco-cutaneous  border  and  entirely  inside  of  the 
anus. 

Inter  no-external,  Mixed,  or  Compound  Hcpmorrhoids. — Those  situated 
partially  above  and  partially  below  the  muco-cutaneous  border. 

Bleeding  or  open  piles,  HcBmorrhoides  Fluentes  sen  cruentce. — Those 
from  which  there  is  a  loss  of  blood. 

Accidental  Iloemorrhoids. — Those  which  are  produced  by  some  acci- 


HAEMORRHOIDS- PILES  593 

dent  or  injury,  either  externally  or  within,  but  A\'hich  develop  sud- 
denly and  are  either  cured  or  pass  away  spontaneously  in  a  short  time. 

Constitutional  Hmnorrlioids. — Those  due  to  some  constitutional  con- 
dition, such  as  cirrhosis  of  the  liver,  congestion  of  the  lungs,  or  cardiac 
insufficiency. 

Arterial  Hcemorrlioids. — Those  in  which  the  tumor  is  chiefly  com- 
posed of  arteries  instead  of  veins. 

Venous  Hwmorrlioids. — Those  composed  chiefly  of  convoluted  veins. 

C  a  pillar  y  Hcemorrlioids. — These  are  small  raspberry-like  tumors  com- 
posed chiefly  of  small  capillary  blood-vessels  covered  with  a  very  thin 
and  fragile  mucous  membrane  which  is  easily  torn. 

Fleshy  Hcemorrlioids,  C onnective-tissue  Hcemorrlioids,  Cutaneous  Piles. 
— These  are  composed  chiefly  of  connective  tissue  without  much  vascular 
development.  They  are  always  external,  and  generally  the  result  of  an 
inflammatory  condition  in  one  of  the  muco-cutaneous  folds  about  the 
anus.  Hypertrophy  of  the  anal  papillse  is  sometimes  spoken  of  as  fleshy 
haemorrhoids,  but  this  use  of  the  term  is  incorrect.' 

Itching  Piles. — This  term  is  applied  to  a  number  of  conditions,  but 
chiefly  refers  to  those  cases  of  pruritus  ani  which  are  associated  with 
haemorrhoidal  disease.  It  implies  that  the  itching  is  due  to  the  piles, 
a  very  unwarranted  assumption,  but  one  which  is  firmly  rooted  in  the 
popular  mind. 

White  Hcemorrlioids. — Eichet  has  used  this  term  to  describe  a  chronic 
condition  of  piles  in  which  the  mucous  membrane  has  assumed  a  muco- 
cutaneous character  and  the  haemorrhages  have  been  supplanted  by  a 
periodic  or  constant  discharge  of  mucus  (Irish  Hospital  Gazette,  July 
13,  1874). 

Infammatory  Hcemorrlioids. — This  term  is  applied  to  any  haemor- 
rhoids which  are  in  a  state  of  inflammation.  It  should  be  confined  to 
that  variety  which  is  due  to  an  acute  inflammation  in  the  muco-cuta- 
neous folds  about  the  margin  of  the  anus. 

Classification.- — Haemorrhoids  are  broadly  classified  as  external  and 
internal.  Those  above  the  margin  of  the  anus  and  out  of  sight  are 
called  internal,  and  those  below  and  in  full  view  are  called  external. 
The  terms,  however^,  have  a  wider  and  more  definite  meaning  from  an 
anatomical  point  of  view.  By  internal  hemorrhoids  are  understood 
those  which  are  developed  from  the  internal  or  superior  hsemorrhoidal 
vessels;  by  external,  those  which  come  from  the  external  or  inferior  ones. 
Piles  do  not  develop  from  the  middle  haemorrhoidal  veins.  It  will  be 
remembered  that  in  the  normal  condition  the  superior  haemorrhoidal 
vessels  are  limited  by  the  muco-cutaneous  border  of  the  anus;  that  the 
little  pools  in  which  the  veins  originate  are  situated  just  above  this 
margin  in  the  submucous  tissues,  and  that  their  connection  with  the 
38 


594  THE   ANUS,   RECTUM.   AND   PELVIC  COLON 

external  veins  i.<  ihrough  tlie  most  minute  venous  capillaries.  So  long 
as  the  sphincter  is  normally  contracted  even  these  small  capillary  com- 
munications are  practically  occluded.  When  it  is  relaxed  the  veins  of  the 
two  systems  can  freely  communicate.  After  this  has  taken  place  both 
sets  of  vessels  may  become  involved  in  the  same  tumor  and  the  result 
is  a  mixed  hcpmorrhoid.  Thus  we  have  a  third  variety,  the  symptoms  and 
characteristics  of  which  are  simply  a  combination  of  those  found  in  the 
other  two.  They  are  usually  treated  as  internal  haemorrhoids,  and  we 
shall  so  consider  them. 

External  Haemorrhoids. — For  the  purposes  of  discussion  and  a 
clear  understanding,  external  haemorrhoids  may  be  classified  as  throm- 
botic external  haemorrhoids,  varicose  external  haemorrhoids,  inflamma- 
tory external  hannorrhoids,  connective-tissue  hemorrhoids. 

Thrombotic  External  Piles. — These  are  small  oval  or  round  tumors 
situated  just  beneath  the  skin  or  muco-cutaneous  surface.  The  color 
of  the  overlying  tissue  may  be  unchanged,  or  it  may  be  a  light  red,  vary- 
ing from  this  to  a  dark'  blue,  according  to  the  thickness  of  the  covering 
and  the  amount  of  distention.  They  vary  in  size  from  that  of  a  small 
pea  to  a  walnut  (Plate  IV,  Fig.  1),  and  may  be  single  or  multiple. 

They  come  on  suddenly  with  a  sharp,  cutting  pain,  gradually  in- 
crease in  size,  and  usually  attain  their  full  growth  within  a  few  hours. 
They  may  be  perfectly  round  like  a  shot  beneath  the  skin,  or  they  may 
be  elliptical,  pear-shaped,  or  crescentic.  The  shape  and  consistence  of 
the  tumors  will  depend  largely  upon  the  density  of  the  tissues  in  which 
they  occur.  When  they  develop  in  the  subcutaneous  fatty  tissue  outside 
of  the  margin  of  the  anus  they  are  generally  globular  and  not  very 
dense  or  hard.  When  they  occur  in  the  m\ieo-cutaneoi;s  folds  they  are 
pear-shaped,  hard,  and  painful. 

They  are  produced  by  clotting  of  blood  in  a  varicose  vein,  or  more 
generally  by  the  rupture  of  a  vessel  and  extravasation  of  blood  into  the 
cellular  tissue  surrounding  it.  Their  gradual  enlargement  is  explained 
as  follows:  a  small  rent  occurs  in  the  vein  due  to  muscular  straining, 
traumatism,  or  sliock;  the  blood  continues  to  ooze  from  such  an  open- 
ing, gradually  distending  the  cellular  tissue  surrounding  the  parts,  and 
thus  the  tumor  grows  and  the  blood-clot  becomes  firmer  until  the  pres- 
sure is  sufficient  to  check  the  haemorrhage.  Where  the  pile  is  due  to 
clotting  in  the  vein  there  is  no  real  tumor  but  a  venous  stasis  followed 
by  the  formation  of  a  small  indurated  mass  at  the  spot,  only  recognizable 
by  touch. 

Symptoms. — The  patient  wliile  straining  at  stool,  at  some  athletic 
or  laborious  exercise,  while  standing,  or  sitting  on  a  perforated  seat, 
feels  a  slight  pain,  like  the  prick  of  a  pin,  about  the  anus,  or  has  the 
sensation  of  something  having  given  way.    If  he  examines  himself  short- 


PLATE  IV. 


3.  INTERNAL   H/EMORRHOIDS 
WITH    CEDEMA   OF  ANAL    MARGIN 


4.    PROLAPSING    INTERNAL   H/EMQRRHOIDS 


TYPES  OF  H>£MORRHOIDS 


HJ5M0RRB0TDS— PILES  595 

ly  afterward  he. will  feel  a  small  swelling  iu  the  region  of  the  pain. 
x\fter  the  first  sting  the  pain  is  not  acute  for  a  while,  but  as  the  tumor 
increases  in  size  a  sense  of  tension  followed  by  aching  and  throbbing 
ensues.  The  pain  and  tension  increase  for  the  first  few  hours,  the 
patient  is  unable  to  sit  down  with  comfort,  and  the  movements  of  the 
bowels  are  distressing.  With  the  application  of  heat  or  cold,  and  after 
twelve  to  twenty-four  hours,  the  acuteness  of  the  pain  decreases,  but  a 
sensation  of  weight  and  aching  continues. 

If  the  tumor  is  a  small  one  and  not  situated  within  the  grasp  of  the 
sphincter,  these  symptoms  will  gradually  grow  less  and  less  until  they 
entirely  disappear,  but  if  the  hemorrhage  has  been  of  considerable  size, 
or  if  it  is  in  that  portion  of  the  anus  where  the  muco-cutaneous  tissiie 
is  closely  attached  to  the  muscle,  the  pain  and  tension  will  be  greater, 
exciting  spasm  of  the  sphincter,  and  the  patient  will  not  be  so  quickly 
relieved. 

If  left  alone  these  hgemorrhoids  may  take  one  of  three  courses.  The 
whole  thing  may  become  absorbed  and  pass  away,  a  very  rare  although 
happy  outcome;  the  clot  may  become  organized,  and  remain  as  an  en- 
cysted body,  which  sometimes  becomes  calcified,  giving  considerable 
inconvenience,  and  at  others  producing  nothing  more  than  a  knowledge 
of  its  presence;  it  may  become  infected,  resulting  in  an  abscess,  or  finally 
in  a  fistula  of  some  variety.  The  method  of  infection  is  through  the 
glands  of  the  skin  and  muco-cutaneous  tissue.  The  extravasation  occurs 
so  near  the  surface  that  the  mouths  of  these  glands  communicate  with 
the  invaded  area,  and  the  infectious  germs  which  are  always  present 
in  these  glands  and  hair  follicles,  finding  a  congenial  medium  in  the 
clot  and  serum  surrounding  it,  thus  develop  an  infection  with  its  conse- 
quent results.  Where  this  takes  place  the  condition  then  assumes  the 
aspect  of  a  perianal  abscess,  and  no  longer  belongs  to  the  category  of 
hgemorrhoids;  such  abscesses  Avhen  opened  discharge  masses  of  broken- 
down  clots  clearly  showing  their  origin. 

Of  these  courses  only  the  first  can  give  a  satisfactory  result.  Where 
the  clot  is  encysted  or  becomes  calcified,  it  is  always  a  source  of  irri- 
tation; especially  is  this  so  if  it  is  high  enough  up  to  be  within  tlie 
grasp  of  the  external  sphincter.  Here  it  acts  exactly  as  a  foreign 
body,  causing  spasm  of  the  muscle,  giving  pain  when  the  bowels  move, 
and  often  creating  distinct  discomfort  when  the  patient  sits  upon  a 
hard  chair  or  rides  horseback.  It  is  not  necessary  to  go  into  detail 
with  regard  to  the  unfortunate  results  when  they  have  become  infected 
and  produce  abscesses  or  fistulas. 

Treatment. — Temporizing  Avith  tliis  variety  of  piles  is  a  very  faulty 
policy.  There  is  but  one  sure  and  scientific  method  to  deal  with  them, 
and  that  is  immediate  enucleation  of  the  clots;  these  are  sometimes  sin- 


596  THE   ANUS,  RECTUM,  AND  PELVIC  COLON 

gle  and  giobular,  at  otliers  they  arc  multiple,  irregular  in  shape,  and 
distributed  throughout  the  convolutions  of  the  vein.  The  treatment, 
however,  is  one  and  the  same.  The  parts  should  be  cleansed  with  anti- 
septic jn'ecautions,  and  a  3-per-cent  solution  of  cocaine  injected  hypo- 
dermically  into  the  swelling.  An  incision  should  then  be  made  vertically 
in  the  line  of  the  radial  folds  well  down  into  the  tissues,  exposing  the 
clot,  which  should  then  be  carefully  seized  with  a  tissue  forceps  and 
dragged  from  its  seat. 

Squeezing  of  the  swollen  and  oedematous  tissues  in  order  to  force 
the  clot  out  is  wrong,  inasmuch  as  the  bruising  and  traumatism  will 
cause  congestion  in  the  parts  and  delay  healing.  Where  there  is  con- 
siderable hypertrophy  and  cedenia  of  the  connective  tissues,  and  numbers 
of  these  little  tlirombi,  one  may  with  advantage  catch  these  tissues  and 
carefully  dissect  them  out  with  scissors  until  all  the  clots  have  been  re- 
moved and  the  swollen  mass  reduced  to  its  normal  size.  This,  however, 
is  rarely  necessary.  Usually  if  one  places  his  left  forefinger  within  the 
anus  and  presses  down  gently  from  above,  while  scraping  the  tissues 
with  a  dull  rectal  scoop,  the  clots  will  slip  out  one  after  the  other  until 
they  are  all  removed.  After  this  is  done,  a  small  piece  of  iodoform 
gauze  should  be  crowded  into  the  cavity,  and  pressed  well  between 
the  lips  of  the  wound;  it  may  be  covered  with  flexible  collodion  for 
the  first  twenty-four  hours,  in  order  to  protect  the  parts  in  case 
of  a  movement  of  the  bowels.  This  packing  of  the  cavity  is  not 
intended  to  check  haemorrhage,  for  practically  there  is  none;  but  it  is 
designed  to  prevent  oozing  and  reproduction  of  the  clot,  which  is  very 
likely  to  occur  if  the  edges  of  the  wound  are  sewed  together  or  allowed 
to  become  approximated  immediately.  The  fear  of  producing  fissure 
by  this  method  is  absolutely  unfounded;  the  incision  rarely  goes  more 
than  a  few  lines  above  the  lower  margin  of  the  external  sphincter,  the 
wound  is  not  within  its  grasp,  and  if  asepsis  is  properly  observed  it 
heals  in  two  or  three  days. 

Some  authors  advise  cutting  away  these  haemorrhoids  and  suturing 
the  skin  together.  Where  the  thrombus  occurs  in  an  already  well-de- 
veloped skin-tab  this  may  be  done.  The  objection  to  this  method  is  that 
which  operative  surgeons  are  urging  against  through  and  through  sutur- 
ing of  skin  wounds  in  other  portions  of  the  body.  There  is  no  doubt 
that  the  skin  and  its  emunctories  are  the  hiding-place  of  many  septic 
and  infectious  germs,  and  the  passage  of  sutures  and  needles  through 
this  tissue  is  very  likely  to  carry  infection  into  a  wound.  This  is  espe- 
cially true  about  the  anus.  Occasionally  excellent  results  are  obtained 
in  plastic  operations  in  this  region,  but  every  operator  must  admit  that 
it  is  the  exception  rather  than  the  rule  that  he  fails  to  have  a  little  pus 
around  sTitures  in  these  parts.     Subcutaneous  sutures  are  very  difficult 


HAEMORRHOIDS— PILES  691 

to  apply  here,  and  the  few  attempts  to  do  so  have  proved  unsatisfactory; 
therefore,  until  a  method  is  perfected  which  will  avoid  the  dangers  of 
this  infection,  it  will  be  better  in  the  treatment  of  thrombotic  haemor- 
rhoids, whether  large  or  small,  to  remove  the  thrombus  and  hypertro- 
phied  portions,  and  pack  the  wound  as  advised  above. 

The  removal  of  the  clot  gives  almost  immediate  relief  to  the  pain. 
On  the  following  day,  when  the  gauze  is  removed,  the  parts  will  ap- 
pear perfectly  clean  and  the  wound  like  a  fresh  cut.  The  edges 
being  then  allowed  to  approximate,  they  rapidly  heal,  sometimes  in 
two  or  three  days,  and  the  patient  is  perfectly  well.  This  method 
of  treatment  applies  quite  as  well  to  the  encysted  and  calcified 
thrombi  as  to  those  just  formed,  and  should  be  carried  out  at  the 
first  examination.  A  patient  with  such  a  condition  should  never  leave 
the  office-table  until  the  clot  has  been  removed.  It  is  very  simple  to 
say  to  them:  "You  have  a  little  clot  here  which  needs  to  be  let  out; 
this  can  be  done  with  no  more  pain  than  the  pricking  of  a  needle,"  and 
no  one  will  object  to  it.  It  may  be  thought  wise  by  some  operators  to 
impress  their  patients  with  the  gravity  of  their  condition  by  magnifying 
this  little  procedure  into  a  surgical  operation,  and  thus  justify  them- 
selves in  charging  a  proportionately  large  fee  for  the  same.  The  con- 
scientious surgeon,  however,  will  never  descend  to  any  such  scheme  or 
trickery  to  augment  his  professional  reputation  or  add  to  his  bank 
account. 

These  tumors  being  practically  without  the  grasp  of  the  sphincter, 
it  is  unnecessary  to  dilate  this  muscle  in  their  treatment.  When  there 
are  more  than  one  they  should  all  be  treated  in  the  same  manner  at  one 
sitting.  When  these  piles  exist  in  connection  with  internal  hgemorrhoids, 
some  authors  advise  leaving  the  former  alone  until  an  operation  for 
internal  haemorrhoids  can  be  arranged,  and  do  them  all  at  once.  This 
method  of  procedure  seems  inadvisable  in  acute  cases,  because  every  day 
that  one  of  these  little  clots  remains  beneath  the  skin  or  muco-cutaneous 
tissues  about  the  margin  of  the  anus,  just  so  much  longer  is  the  patient 
exposed  to  the  dangers  of  infection,  abscesses,  and  fistula.  They  have 
no  connection  with  internal  haemorrhoids,  and  as  the  latter  are  treated 
in  the  majority  of  instances  by  open  methods,  necessitating  a  certain 
amount  of  suppuration,  this  is  more  than  likely  to  infect  the  area  from 
which  the  thrombus  has  been  removed,  and  cause  delay  in  healing  or  ul- 
ceration at  these  points.  In  such  cases  the  clot  should  be  removed  from 
the  thrombotic  htemorrhoid  upon  the  first  examination,  and  the  patient 
advised  to  wait  until  the  wound  has  healed  before  having  anything  done 
for  the  internal  haemorrhoids. 

Varicose  External  Hcemorrhoids. — This  variety  consists  in  a  varicose 
condition  of  the  subcutaneous  veins  surrounding  the  margin  of  the  anus. 


598  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

All}-  one  who  has  operated  about  the  rectum,  or  who  has  ever  observed 
these  parts  while  the  patient  was  bearing  down,  must  have  noticed  how 
easily  the  external  plexus  of  veins  becomes  dilated  and  distended  under 
these  circumstances.  This  dilatation  takes  place  at  every  movement  of 
the  bowel  when  there  is  any  straining. 

It  is  therefore  very  common  in  people  who  are  constipated  or  who 
sit  for  long  periods  in  one  position,  especially  upon  perforated  seats  or 
at  stool.  The  veins  are  equably  dilated  and  the  circulation  continues, 
althoi;gh  impeded  somewhat  by  the  loss  of  elasticity  in  the  vessel  walls. 
Like  varicose  veins  of  the  leg,  they  are  onh'  present  when  the  patient 
is  in  the  proper  position.  In  sitting,  squatting,  or  straining  with  the 
abdominal  muscles  they  appear,  and  sometimes  reach  enormous  dimen- 
sions, forming  as  it  were  a  regular  crown  of  haemorrhoids  around  the 
anus;  and  yet,  immediately  after  the  horizontal  position  is  resumed  and 
the  straining  ceases  they  disappear  entirely. 

They  may  also  be  caused  to  disappear  even  in  tlie  sitting  or  squatting 
posture  by  firm  pressure  upon  the  parts,  showing  that  there  is  very 
little  increase  in  the  connectiA'e  tissue  and  no  permanent  hypertrophy. 
This  sometimes  deceives  the  patient,  causing  him  to  think  that  they  are 
internal  haemorrhoids  which  pass  inside  of  the  bowel. 

Symptoms. — In  this  variety  the  growth  is  of  an  insidious  and  slowly 
progressive  nature.  There  is  no  pain,  no  sudden  development  or  pro- 
trusion, and  no  obstruction  to  the  functional  action  of  the  bowels.  The 
majority  of  patients  are  rarely  aware  of  their  presence  unless  they  be- 
come quite  marked.  It  is  only  in  the  hypersensitive,  overparticular,  and 
nervous,  who  in  the  use  of  detergents  become  aware  of  an  unnatural 
condition  of  the  parts,  that  much  attention  is  paid  to  them.  The  un- 
easiness which  they  produce  is  more  mental  than  physical. 

These  piles  do  not  conform  to  the  folds  of  the  rectum;  they  are  not 
lobulated  or  easily  outlined;  they  form  a  general  swelling  or  cushion- 
like mass  around  the  margin  of  the  anus,  and  sometimes  give  one  the 
impression  of  an  inflated  rubber  pessary  covered  with  skin  and  muco- 
cutaneous tissue,  with  a  bluish  tinge  that  indicates  the  venous  origin. 

Treatment. — These  liEemorrhoids,  being  brought  about  through  habit 
and  environment,  are  amenable  to  treatment  by  the  regulation  of  those 
factors.  As  a  rule  they  do  not  require  any  surgical  operation.  The  pa- 
tient should  avoid  prolonged  sitting  and  straining  at  stool;  the  constipa- 
tion which  generally  exists  should  be  remedied  before  any  attempt  at 
treatment  of  the  piles;  tight,  spasmodic  sphincters  should  be  gradually 
dilated,  obstructive  rectal  valves,  strictures,  catarrhal  diseases,  and  what- 
ever causes  constipation  or  obstipation  should  all  be  carefully  treated 
and  removed  if  possible.  If  there  be  none  of  these  pathological  condi- 
tions to  accoimt  for  them,  their  treatment  may  be  based  upon  the  lines 


HEMORRHOIDS— PILES  599 

of  dietary  and  physical  regimen.  In  order  to  avoid  the  necessity  of  re- 
maining long  at  stool  the  patient  should  be  instructed  to  take  an  enema 
of  about  half  a  pint  of  cold  water  at  some  hour  at  which  it  is  convenient 
for  him  to  attend  to  the  movement  of  his  bowels  regularly.  As  soon  as 
he  feels  a  strong  inclination  for  this  to  come  away,  he  should  repair  to 
the  toilet,  and  without  straining  he  will  generally  be  relieved  of  what- 
ever fgecal  matter  is  present  in  the  rectum  and  sigmoid.  He  should  be 
instructed  not  to  sit  at  stool  any  longer  than  two  or  three  minutes,  after 
which  he  should  go  to  his  bed,  lie  down  with  his  hips  elevated,  and 
apply  cold  cloths  to  the  anus  for  five  or  ten  minutes.  Night  is  generally 
more  convenient  for  men,  but  for  women  whose  duties  are  at  home,  any 
hour  may  be  selected  in  which  they  are  least  likely  to  be  interrupted. 
The  important  thing  is  to  have  a  regular  time  for  this  function,  and  to 
hold  it  inviolable.  After  a  short,  conscientious  devotion  to  these  regu- 
lations the  bowels  will  soon  become  habituated  to  regular  action,  and 
frequently  the  movement  occurs  without  the  enema.  At  bedtime  these 
patients  should  apply  the  following  ointment: 


I^  Ung.  acidi  tannice 3iv; 

Ung.  stramonii,     )  _-   ,-. 

*=  '     L    aa  53. 

Ung.  belladonnge,  f 

M.  et  ft.  ung. 
Or, 

I^  Ext.  suprarenalis  3ij; 

Ung.  lanolini   3vj. 

M.  et  ft.  ung. 

The  ointment  should  be  spread  thickly  over  a  wad  of  cotton  wool, 
and  held  in  apposition  with  the  parts  by  a  T-bandage. 

One  should  be  warned  against  the  use  of  drastic  purgatives  in  this 
condition.  They  cause  frequent  stools  and  straining,  and  will  aggravate 
rather  than  relieve  it.  The  ftecal  movements  should  be  kept  soft  but 
without  purgation.  A  diet  of  meat,  fruit,  fresh  vegetables,  and  Graham 
or  whole  wheat  bread  should  be  enjoined. 

The  patient  should  always  lie  down  to  make  the  cold  applications, 
and  should  have  his  hips  elevated  above  the  level  of  the  chest.  Doing 
this  in  the  squatting  position  accomplishes  very  little  good.  Outdoor 
exercise,  walking,  golf,  tennis,  and  such  diversions  are  very  beneficial  in 
these  cases.  Where  there  are  no  internal  haemorrhoids,  and  where  the 
patient  can  be  induced  to  carry  out  this  regimen,  the  varicose  external 
hgemorrhoids  can  generally  be  relieved  in  a  period  varying  from  three 
to  six  weeks.  Where  there  are  internal  haemorrhoids,  however,  and 
inflammatory  conditions  of  the  rectum  which  cause  straining,  irritating 


600  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

discharges,  and  other  symptoms,  we  can  hardly  expect  this  variety  to 
be  greatly  benefited  until  those  conditions  have  been  relieved.  If  an 
operation  for  internal  haemorrhoids  is  thought  necessary  or  desirable, 
one  may  at  the  same  time  remove  a  certain  amount  of  the  varicose  veins 
which  form  this  variety  of  piles,  and  cure  them  both  at  the  same  time. 
One  should  be  careful,  however,  not  to  take  away  too  much  skin  from 
around  the  margin  of  the  anus  lest  a  cicatricial  stricture  should  follow. 

The  author  has  tried  cauterizing  these  piles  by  a  narrow-bladed 
Paquelin  knife,  and  has  been  quite  successful  in  the  cases  in  which  it 
was  used;  but  the  burning  pain  which  follows  this  operation  has  caused 
him  to  discontinue  it.  Kelsey  has  advised  the  use  of  a  fine  needle- 
pointed  cautery,  by  which  he  burns  into  the  varicose  veins  at  different 
points;  this  instrument  has  sometimes  caused  severe  abscesses  on  ac- 
count of  the  external  opening  closing  before  all  the  necrosed  tissues  in 
the  deeper  parts  of  the  tract  had  been  evacuated. 

The  treatment  of  these  tumors  by  injection  has  been  frequently  advo- 
cated. It  is  performed  as  follows:  After  having  thoroughly  cleansed 
the  parts  with  antiseptic  solutions,  the  piles  are  made  tense  and  pro- 
truding by  the  patient's  straining  and  bearing  down;  the  most  prominent 
portions  of  the  varicose  mass  are  then  injected  at  four  or  five  points 
around  the  margin  of  the  anus  with  a  few  drops  of  Shuford's  solution 
(see  p.  637),  or  some  mixture  of  carbolic  acid.  As  a  rule,  however,  this 
treatment  is  not  successful  in  any  form  of  external  haemorrhoids. 

Electrolysis  has  been  recommended  by  a  number  of  surgeons  in  the 
treatment  of  this  variety  of  haunorrhoids,  but  this  method  is  not  as 
effectual  as  the  others  detailed,  and  is  only  safe  in  the  hands  of  an  ex- 
perienced electrician  equipped  with  an  apparatus  by  which  the  strength 
of  the  current  can  be  absolutely  measured.  The  ordinary  office  batteries 
are  unreliable  for  such  purposes.  It  has  been  suggested  that  the  current 
be  tested  in  the  white  of  an  egg,  and  used  only  sufficiently  strong  to 
coagulate  this  substance,  but  this  is  a  very  indefinite  test.  The  positive 
pole  is  attached  to  a  fine  electrolysis  needle  which  is  introduced  well 
into  the  substance  of  the  tumor,  and  the  negative  pole  applied  to  the  but- 
tocks. The  swollen  tissues  may  be  first  injected  with  a  solution  of 
cocaine  if  the  patient  is  hypersensitive.  There  is  some  pain  at  the  time 
of  the  operation  which  increases  during  the  first  twenty-four  hours,  and 
this  is  followed  by  considerable  swelling  and  oedema  of  the  parts;  after 
this  the  swelling  is  said  to  subside  and  the  varicosities  rapidly  disappear. 
After  trying  all  these  methods  the  author  is  convinced  that  the  non- 
operative  treatment  is  by  far  the  most  satisfactory. 

Inflammatory  External  Hcemorrhoids. — This  variety  consists  in  an  in- 
flamed and  swollen  condition  of  the  folds  of  the  anus;  they  are  also 
described  under  the  name  of  oedematous  piles.     They  are  pear-shaped, 


HEMORRHOIDS— PILES  601 

their  small  end  extending  sometimes  within  the  external  sphincter,  and 
have  a  miico-cutaneous  and  cutaneous  covering. 

They  originate  in  some  traumatism  or  irritation  of  the  margin  of 
the  anus.  This  may  be  mechanical  or  pathological.  Anal  or  rectal  ulcer- 
ation, fissures,  chancroids,  improper  detergent  material,  rough  or  too 
vigorous  wiping,  pa3derasty,  rectal  masturbation,  kicks,  injuries,  falls  or 
strains  may  all  produce  them.  Grasping  of  the  upper  portion  of  the 
tumors  by  the  sphincter  may  cause  considerable  pain,  but  it  never  pro- 
duces strangulation  or  sloughing,  as  in  the  case  of  internal  haemorrhoids 
when  they  become  prolapsed.  Sloughing  may  occur,  but  it  is  due  to  the 
inflammatory  processes  and  not  to  strangulation  by  the  sphincter,  as 
their  blood  supply  is  outside  of  this  muscle.  Sometimes  they  originate 
in  a  traumatism  which  causes  hgemorrhage  and  clot  in  the  fold,  and 
there  is  a  combination  of  the  thrombotic  and  inflammatory  types.  In 
such  cases  the  color  of  the  tumor  will  have  a  bluish  tinge,  especially 
when  the  skin  is  drawn  down  and  made  tight  over  the  globular  mass. 

When  it  is  of  a  purely  inflammatory  nature  the  tumor  will  be  pear- 
shaped  or  elliptical,  red,  dense,  swollen,  and  painful. 

Symptoms. — They  may  be  single  or  multiple,  simple  or  complicated. 
The  patient,  if  he  does  not  recognize  a  positive  injury  to  the  parts,  or 
has  no  history  of  previous  rectal  or  anal  afl:ection,  will  generally  notice 
at  first  a  sense  of  heat,  uneasiness,  or  itching.  Upon  examination 
he  will  feel  at  one  or  more  points  around  the  anus  an  increased  prom- 
inence or  a  sort  of  oval  swelling.  The  pain  at  first  will  be  moder- 
ate, and  when  the  inflammation  is  very  mild  it  may  pass  rapidly  away. 
Upon  the  next  irritation,  however,  the  swelling  returns  and  the  pain 
becomes  aggravated.  The  parts  ache  and  burn,  there  is  spasm  of  the 
sphincter,  and  sitting  down  is  painful.  Lying  upon  the  side,  with  the 
hips  elevated,  is  the  most  comfortable  position  which  can  be  assumed. 
Defecation  is  dreaded,  and  constipation  therefore  ensues.  If  the  case 
be  a  severe  one,  constitutional  symptoms  will  appear;  the  temperature 
may  be  elevated  two  or  three  degrees,  the  tongue  coated,  and  the  pulse 
rapid.  Ocular  examination  of  the  parts  will  reveal  one  or  more  swellings 
of  the  shape  already  described  about  the  margin  of  the  anus,  varying 
in  size  from  that  of  a  small  hazelnut  to  a  guinea-egg.  They  are  not 
so  hard  as  thrombotic  hemorrhoids,  and  sometimes  give  the  sensation 
of  fluctuation.  They  are  always  very  painful  to  the  touch,  and  if  they 
be  large,  the  mucous  membrane  will  be  dragged  down  from  within  the 
rectum,  thus  forming  a  part  of  their  covering. 

At  the  base  of  each  tumor,  or  between  tAvo  of  them,  there  will  often 
be  found  a  small  fissure,  ulcer,  or  excoriation.  Sometimes  a  pocket  exists 
at  this  point,  and  in  it  may  be  found  a  hardened  mass  of  fteces,  a  small 
seed,  or  other  foreign  body;  a  shallow,  subtegumentary  fistula  may  some- 


6<»2  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

times  be  found,  the  tract  leading  downward  beneath  the  muco-cuta- 
neous  tissue.  These  hfemorrhoids  may  ulcerate  and  slough,  or  if  the  in- 
flammation subsides,  gradual!}'  slirink  until  they  disappear  or  form  con- 
nective-tissue piles;  the  latter  is  their  usual  course. 

If  the  patient  should  be  in  a  low  physical  condition  and  susceptible 
to  infection,  very  grave  constitutional  symptoms  may  develop.  As  a 
rule  they  are  the  most  painful  of  all  hemorrhoids,  and  one  can  hardly 
credit  the  amount  of  distress  which  may  result  from  them. 

Treatment. — The  treatment  of  these  consists  in  subduing  the  inflam- 
mation by  antiphlogistic  methods  or  in  radical  removal  of  the  tumors. 
Lying  with  the  hips  elevated  and  an  ice-bag  applied  to  the  parts,  will 
often  relieve  them  very  quickly,  but  at  the  same  time  cold  may  cause 
sloughing.  "Where  there  is  much  oedema  and  swelling,  gauze  soaked  in 
a  25-per-cent  solution  of  boroglyceride  should  be  applied,  and  a  hot- 
water  bag  laid  over  this.  As  a  rule  this  simple  measure  will  reduce  the 
inflammation  and  relieve  the  pain.  The  following  ointment  is  also  very 
effectual  in  this  condition: 

I^   ]\Iorphine  sulph gr.  v-x; 

Ichthyol   oiv; 

Ung.  belladonna',  |  __   ... 

Ung.  stramonii,     j    " 

Sig.:  Apply  two  or  three  times  a  day. 

Often  the  pain  is  so  severe  in  these  cases  that  patients  are  willing 
to  submit  to  anything  for  relief,  and  operative  measures  are  the  surest 
way  to  obtain  this.  Some  writers  advise  making  an  opportunity  of  the 
patient's  exigency  under  these  circumstances,  and  to  persuade  them  to 
have  an  operation  to  which  they  are  opposed  by  stating  that  it  is  the 
only  certain  means  of  cure.  Such  methods  are  distasteful.  A  fair,  frank 
statement  of  what  can  be  expected  from  both  methods  of  treatment,  and 
recommendation  as  to  which  is  better  in  the  individual  case  is  a  much 
more  dignified  and  self-respecting  position  for  the  surgeon  to  take;  he 
should  not  deign  to  frighten  a  patient  into  a  course  to  which  his  candid 
advice  does  not  persuade  him.  If  the  operation  is  decided  upon,  general 
anaesthesia  should  be  employed,  inasmuch  as  this  variety  is  often  asso- 
ciated with  fissures,  ulcerations,  and  internal  haemorrhoids,  and  stretch- 
ing of  the  sphincter  is  very  important.  Occasionally,  where  only  one  fold 
is  inflamed  and  the  fissure  is  clearly  in  view,  the  hsemorrhoid  may  be 
removed  and  the  fissure  incised  under  cocaine  anaesthesia.  At  any  rate 
the  sphincter  should  always  be  divulsed  or  incised  in  operations  for  this 
class  of  ha?morrhoids,  otherwise  a  fissure  will  result. 

The  tumor  itself  should  be  removed  by  scissors  or  by  crushing  with 
the  clamp.    Neither  the  ligature  nor  the  cautery  should  be  used  on  the 


HEMORRHOIDS— PILES  603 

skin  tissue  covering  them,  as  they  are  both  very  painful.  After  excising 
the  piles,  the  edges  of  the  wounds  may  be  sutured  together,  but  it  is 
doubtful  if  any  particular  advantage  is  obtained  by  this,  as  infection  is 
nearly  always  present  to  prevent  primary  union.  The  only  advantage 
of  the  operation  over  local  treatment  in  these  cases  is  the  radical  cure 
which  is  obtained.  One  method  relieves  the  pain  about  as  quickly  as 
the  other,  but  after  the  non-operative  treatment  there  are  left  skin-tabs 
or  connective-tissue  piles  which  may  reproduce  the  inflammatory  variety 
at  any  time. 

Connective-tissue  Ilcemorrhoids. — This  variety  of  piles,  called  also 
cutaneous  or  fleshy  piles  and  skin-tabs,  consists  in  hypertrophy  of  the 
muco-cutaneous  tissue  about  the  margin  of  the  anus.  They  appear 
when  not  inflamed  as  flat  folds  or  tabs,  more  or  less  numerous,  and 
sometimes  entirely  surrounding  the  aperture;  the  longest  axis-  may 
run  up  and  down  or  circularly  around  the  anus,  the  base  may  be 
broad  or  constricted.  They  are  generally  composed  entirely  of  muco- 
cutaneous tissue,  with  a  stroma  of  connective  tissue  separating  the 
two  layers  of  the  dermis  in  which  run  one  or  two  arteries  with  their 
accompanying  veins.  The  blood-vessels  are  more  or  less  atrophied 
(Cripps)  and  there  is  an  hypertrophy  of  all  the  elements  of  the  muco- 
cutaneous tissues.  Microscopic  examination  demonstrates,  however, 
that  the  chief  hypertrophy  takes  place  in  the  subcutaneous  connective 
tissues,  and  that  the  term  "  connective-tissue  hsemorrhoids  "  is  there- 
fore more  appropriate  to  the  condition  than  any  other.  They  may 
also  contain  cyst-like  cavities,  the  remains  of  obliterated  veins  that 
give  rise  to  a  condition  resembling  cavernous  tissue.  Small  mucous 
follicles  and  masses  of  fat  may  also  be  found  in  them. 

They  originate  in  three  ways:  they  may  result  from  an  acute  inflam- 
matory haemorrhoid  in  which  the  inflammation  has  subsided,  leaving 
an  hypertrophy  of  the  connective  tissue  and  of  the  skin,  which  tissues 
contract  and  obliterate  to  a  greater  or  less  degree  the  dilated  veins; 
they  may  originate  in  some  chronic  irritation  about  the  anus,  such 
as  fissure,  mild  ulceration,  or  catarrhal  disease;  they  may  follow  throm- 
botic or  varicose  external  haemorrhoids.  When  they  are  developed  from 
the  latter  they  assume  the  circular  type  and  extend  entirely  around 
the  anus.  It  is  not  necessary  for  the  production  of  this  variety  of 
disease  that  the  exciting  cause  should  be  low  down  in  the  rectum. 
The  condition,  as  has  been  seen,  results  from  strictures,  ulcers,  and 
malignant  diseases  as  high  up  as  the  sigmoid  flexure.  It  has  been 
claimed  in  such  conditions  that  the  connective-tissue  ha?morrhoids  are 
probably  due  to  the  irritating  discharge  of  the  original  disease.  The 
French  authors  claim  that  these  skin-tabs,  or  "  rhagades "  as  they 
call  them,  are  indicative  of  syphilitic  disease.     When  associated  with 


6Ui  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

hard,  inelastic  stricture  and  ulceration  of  the  rectum  one  may  undoubt- 
edly suspect  this  origin,  but  when  not  complicated  by  such  a  condition 
they  are  no  more  indicative  of  syphilis  than  of  malignant  or  chronic 
inflammatory  diseases  of  the  rectum. 

There  are  cases  of  this  variety,  however,  in  which  there  is  no 
condition  in  the  anus  to  account  for  them;  they  occur  in  lads  fourteen 
and  fifteen  years  of  age,  who  have  no  recollection  whatever  of  having 
had  any  anal  or  rectal  disease,  and  are  absolutely  free  from  syphilis. 
It  is  possible  that  in  these  cases  phimosis  or  sexual  excitement  may 
have  caused  the  congestion  or  hypera?mia  which  produced  them. 

Symptoms. — Hsemorrhoids  of  this  variety,  when  in  their  quiescent 
stage,  can  scarcely  be  said  to  produce  any  symptoms  peculiar  to  them- 
selves. They  are  not  painful,  they  do  not  bleed,  pressure  will  not  cause 
them  to  disappear,  they  can  not  be  kept  inside  of  the  sphincter,  and 
they  have  no  peculiar  outline  or  color.  They  may  be  single  or  multiple, 
thick  or  thin,  pedunculated  or  broad  and  flat  at  their  bases.  They  are 
supplied  by  one,  sometimes  two  small  arteries;  the  number  of  veins 
varies  according  to  the  stage  of  development.  They  become  inflamed 
by  slight  traumatisms,  such  as  sitting  upon  a  hard  scat,  horseback  or 
bicycle  riding,  the  passage  of  constipated  stools,  and  too  vigorous 
cleansing.  Excessive  eating  or  drinking,  sudden  exposure  to  cold 
after  being  overheated,  and  chafing  in  hot  weather,  will  also  excite 
inflammation  in  them.  When  this  occurs  the  symptoms  correspond 
to  those  of  inflammatory  piles. 

Treatment. — Where  these  piles  are  uncomplicated  by  fissure,  ulcera- 
tion, or  internal  haemorrhoids,  they  should  not  be  molested  unless  they 
become  inflamed  or  their  presence  annoys  the  patient  mentally;  if 
one  finds  it  best  to  remove  them,  this  can  be  done  under  cocaine  by 
crushing  them  off  with  the  hagmorrhoidal  clamp.  By  this  means  the 
edges  adhere,  and  being  sealed  by  collodion  and  iodoform,  they  gen- 
erally unite  as  if  sutured. 

Perfectly  satisfactory  results  may  be  obtained  by  simply  cli])ping 
off  the  hypertrophies  with  scissors  and  leaving  the  wounds  to  granulate. 
It  is  very  important,  however,  to  cut  flush  with  the  skin  and  leave 
no  stump.  When  they  are  extensive,  with  broad  bases,  a  more  rapid 
cure  may  be  obtained  by  cutting  them  off  and  suturing  the  edges  of 
the  wound  together. 

Internal  Haemorrhoids. — While  a  great  many  varieties  of  internal 
hemorrhoids  have  been  described  in  literature,  there  are  practically 
but  four  varieties.  They  may  be  classified  as  thrombotic  internal 
haemorrhoids,  varicose  internal  haemorrhoids,  capillary  internal  hfemor- 
rhoids,  and  mixed  haemorrhoids. 

Hamilton  (Clinical  Lectures  on  Diseases  of  the  Lower  Bowel,  p.  32) 


HEMORRHOIDS— PILES  605 

describes  a  variety  which  he  calls  columnar  hceniorrhoids,  as  follows: 
"  The  second  variety,  for  which  I  would  suggest  the  term  columnar  pile 
to  denote  its  pathology,  consists  essentially  in  hypertrophy  of  the  folds 
of  mucous  membrane  surrounding  the  anal  opening,  the  pillars  of 
Glisson.  They  have  a  red,  almost  vermilion  color,  elongated  form, 
and  contain  within  them  one  of  the  descending  circular  branches  of 
the  superior  hemorrhoidal  arteries." 

Ball  states  that  this  is  the  most  common  variety  of  internal  hgemor- 
rhoids.  According  to  his  microscopic  examinations  they  consist  of 
inflammatory  hypertrophies  in  Avhich  there  are  no  varicosities.  It 
appears,  however,  from  the  descriptions  of  these  authors,  that  they 
refer  either  to  inflammatory  external  hgemorrhoids  or  to  simple  inflam- 
matory conditions  of  the  rectal  columns.  Such  conditions  occasionally 
occur,  but  they  can  not  be  classified  as  true  internal  haemorrhoids. 

Thrombotic  Internal  Hcemorrlioids. — These  consist  in  an  extravasa- 
tion and  clotting  of  blood  in  the  submucous  tissues,  and  differ  from 
external  thrombotic  hemorrhoids  only  in  the  location  and  overlying 
tissues.  They  may  occur  in  an  otherwise  healthy  rectum,  but  gener- 
ally complicate  varicose  piles. 

They  are  less  painful  than  external  thrombotic  jDiles,  but  sometimes 
produce  an  irritation  and  bearing-down  in  the  rectum.  To  the  touch 
they  feel  like  small  globular  or  elliptical  tumors,  movable  beneath  the 
mucous  membrane  and  over  the  muscular  wall.  They  present  to  the 
eye  only  a  slight  elevation,  as  the  overlying  tissues  are  never  sufficiently 
distended  for  the  blue  color  of  the  clot  to  show  through  it. 

They  are  so  rare,  except  in  connection  with  internal  varicose  haemor- 
rhoids, that  it  is  difficult  to  give  any  definite  description  of  their  course 
and  final  results.  The  writer  has  seen  2  cases  in  which  the  clot  became 
encysted,  and,  when  turned  out  of  its  capsule,  appeared  as  an  ovoid 
mass,  hard,  smooth,  shining,  and  of  a  deep  purple.  They  very  rarely 
become  infected  or  form  abscesses.  The  treatment  consists  in  evacua- 
ting the  clot  or  removing  the  varicose  mass  in  which  they  occur. 

Varicose  or  Venovs  Internal  Hcemorrlioids. — This  is  the  most  fre- 
quent variety  of  haemorrhoids.  It  consists  in  a  varicosity  of  the 
internal  hemorrhoidal  veins  with  hypertrophy  of-  the  connective-tissue 
stroma  in  which  these  vessels  lie. 

They  originate  in  the  little  venous  pools  which  connect  the  arterial 
with  the  venous  circulation.  In  the  beginning  they  are  simply  con- 
gestions of  the  vessels.  Pressiire  of  the  blood-column,  straining  at 
stool,  the  friction  of  faecal  passages,  and  other  causes  produce  dilata- 
tion of  the  veins,  hyperemia  of  the  parts,  and  hypertrophy  of  the  con- 
nective tissue,  until  veritable  angeiomatous  tumors  are  formed.  These 
are   ordinarily   located   at   three   points   in   the   circumference   of   the 


C06 


THE  AXUS,   RECTUM,  AND   PELVIC   COLON 


rectum:  one  upon  each  side  and  sligiitly  in  front  of  the  posterior  com- 
missure, and  one  upon  the  right  side  and  slightly  behind  the  anterior 
commissure.  Sometimes  there  is  a  fourth  prominent  one  upon  the 
left  side  of  the  anterior  commissure  (Plate  IV,  Fig.  2),  but  this  is  not 
ordinarily  well  developed. 

Between  these  three  prominent  tumors  there  is  generally  a  varicose 
condition  of  the  veins,  and  sometimes  small  ha?morrhoidal  tumors  may 
develop.  These,  however,  are  of  little  importance  from  a  surgical 
point  of  view,  Avith  the  exception  of  one,  which  sometimes  occurs 
immediately  above  the  posterior  commissure.  Occasionally  the  whole 
circumference  is  involved  in  the  varicose  process,  and  the  anus  when 
it  is  dilated  presents  a  veritable  rosette  of  hfemorrhoidal  tissue,  only 
slightly  more  prominent  in  one  portion  than  another.  They  begin 
abruptly  at  the  ano-rectal  line,  and  are  covered  entirely  with  mucous 
membrane.     In  their  early  stages,  when  quiescent,  they  lie  dormant 

and  collapsed  within  the  rec- 
tum, and  can  neither  be  seen 
nor  felt  unless  the  patient  by 
bearing  do\\Ti  protrudes  them. 
Except  when  inflamed  and 
swollen  their  surface  is  irregu- 
lar, lobulated,  and  crossed  by 
numerous  furrows  running  in 
different  directions,  produced 
by  the  attachments  of  connect- 
ive-tissue stroma  to  the  mucous 
membrane.  When  they  have 
been  prolapsed  for  some  time 
or  become  inflamed  these  fur- 
rows practically  disappear,  and 
the  tumors  present  a  globular 
shape  with  smooth,  shining  sur- 
faces (Plate  lY,  Fig.  3).  Allien 
the  disease  has  become  chronic 
and  the  connective-tissue  stro- 
ma hypertrophied,  the  tumors 
can  then  be  brought  into  view 
by  separating  the  folds  of  the 
buttocks  and  dragging  down  upon  the  margin  of  the  anus,  or  they 
may  be  felt  by  the  finger.  If  the  tumors  are  habitually  prolapsed  the 
mucous  covering  may  assume  a  muco-cutaneous  character. 

Their  shape  is  variable;  they  may  be  globular  or  cone-shaped,  and 
attached  by  a  broad  base;  they  may  be  pedunculated  or  semicircular. 


Fig.  193. — Prolapsed  Intern.\i.  II.emorriioid 
WITH  Condyloma  attached. 


HEMORRHOIDS— PILES  607 

involving  almost  the  entire  circumference  of  flie  rectum.  Sometimes 
small  polypi  or  condylomata  are  attached  to  them  (Fig.  193).  Their 
lower  margin  is  sharply  delineated  by  the  white  line  of  Hilton,  and 
even  where  they  are  connected  with  external  hasmorrhoids  this  line  still 
marks  the  division  betAveen  the  two. 

Pathology. — The  tumors  consist  essentially  of  congeries  of  dilated 
blood-vessels  and  connective-tissue  stroma.  Upon  section  they  present 
a  sort  of  sponge-like  or  honeycomb  appearance,  due  to  the  dilated  veins 
and  a  few  arteries  held  together  by  a  complicated  network  of  connective 
tissue  in  which  are  found  epithelial  and  glandular  cells.  They  resemble 
very  much  the  erectile  tissue  found  in  the  spongy  body.  In  the  cavities 
of  the  veins  the  section  shows  coagulated  blood,  thickening  of  the  in- 
tima,  and  sometimes  an  inflammatory  deposit  in  the  blood-vessel  walls, 
but  generally  these  are  thin  and  friable.  The  coagulation  takes  place 
after  the  hemorrhoid  is  removed,  and  is  not  an  essential  part  of  its 
pathology.  The  arterial  supply  of  the  ordinary  venous  hsemorrhoid  is 
not  through  one  main  branch,  but  through  a  number  of  arterial  capil- 
laries. Sometimes,  however,  one  large  artery  runs  into  the  tumor  and 
can  be  felt  pulsating  when  the  finger  is  pressed  above  it.  The  tumors 
are  connected  with  the  muscular  wall  of  the  gut  by  very  feeble  adhesion, 
and  can  be  peeled  off  both  in  life  and  post-mortem  with  the  greatest  ease, 
especially  if  the  stripping  be  from  above  downward. 

The  muscles  at  this  portion  of  the  gut  are  supplied  by  the  middle 
hgemorrhoidal  arteries,  and  at  two  or  three  points  around  the  circum- 
ference of  the  rectum  there  is  a  more  intimate  adhesion  to  the  mus- 
cular wall,  due  to  penetration  by  branches  of  these  vessels.  In  the 
early  stages  the  mucous  covering  is  normal,  but  in  old  hsemorrhoids 
it  is  thickened,  more  dense  in  its  composition,  and  the  Lieberkiihn 
follicles  are  very  much  atrophied,  or  may  have  disappeared  entirely. 
Sometimes  there  are  little  areas  of  cicatrization  indicating  points  at 
which  there  have  been  haemorrhages  or  ulcerations.  In  the  cases  of 
general  varicosity  associated  with  diseases  of  the  heart,  liver,  or  spleen, 
the  condition  may  occupy  the  whole  length  of  the  rectum  and  ascend 
even  up  into  the  colon,  as  has  been  described  by  Ludwig,  Petit,  and 
Valsalva. 

The  form  of  haemorrhoids  called  "  arterial "  by  Allingham,  and 
described  as  being  composed  of  congeries  of  arterial  capillaries  instead 
of  veins,  is  not  admitted  by  the  majority  of  authors.  This  idea  came 
from  the  fact  that  the  blood  sometimes  comes  in  jets  or  spurts.  This 
is  explained  by  Cripps,  as  follows:  "  The  jet  is  caused  by  blood  being 
forced  as  a  regurgitant  stream  through  a  small  rupture  in  a  vein  by 
the  powerful  pressure  of  the  abdominal  muscles.  If  it  really  came 
from  an  artery,  why  did  the  jet  only  appear  when  the  abdominal  mus- 


608  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

cles  acted?"  He  holds  that  if  the  bleeding  of  an  artery  was  the  cause, 
straining  and  pressure  would  diminish  rather  than  increase  the  spurt- 
ing. In  one  instance  of  this  kind  he  was  able  to  discover  a  clot  ob- 
structing a  small  circular  opening  in  the  vein  itself,  and  when  this 
was  removed  to  reproduce  the  spurting  by  causing  the  patient  to  strain 
with  the  abdominal  muscles.  His  experience  and  the  examination  of 
many  specimens  of  haemorrhoids  removed  during  life  and  post-mortem 
seem  to  justify  his  position;  and,  notwithstanding  the  authority  of  Van 
Buren,  Brodie,  and  Allingham,  the  author  is  convinced  that  aside  from 
the  capillary  variety  there  is  no  such  condition  as  arterial  haemor- 
rhoids. 

Symptoms. — The  two  cardinal  symptoms  of  internal  hsemorrhoids 
are  bleeding  and  protrusion;  it  is  difhcult  to  say  which  symptom  is  most 
frequently  first  observed.  A  slight  oozing  of  blood  very  frequently 
occurs  unobserved  by  the  patient,  and  his  attention  is  not  called  to  this 
loss  until  he  feels  an  unusual  protrusion  about  the  margin  of  the  anus; 
when  this  is  felt  he  generally  examines  his  faecal  passages  and  the 
loss  of  blood  is  discovered. 

In  uncomplicated  internal  haemorrhoids  there  is  practically  no  pain 
and  no  obstruction  to  the  passage  of  the  fsecal  mass.  Bleeding  may 
recur  from  time  to  time,  especially  in  the  lower  classes,  who  do  not 
watch  themselves  closely,  and  go  on  for  long  periods  without  its  ever 
being  suspected;  whereas  protrusion,  as  soon  as  it  occurs,  will  ])e  noticed 
and  excite  the  anxiety  of  the  patient. 

In  the  varicose  variety  the  hagmorrhage,  while  not  so  frequent  as 
in  the  capillary,  is  sometimes  excessive  in  quantity,  resulting  in  dizzi- 
ness and  fainting;  such  cases,  however,  are  exceptional.  The  patient 
generally  observes  a  small  amount  of  blood  following  a  movement  at 
stool.  At  first  this  loss  occurs  only  occasionally,  but  after  they  have 
existed  for  some  time  and  begin  to  prolapse,  the  haemorrhages  occur 
more  frequently  at  stool,  and  may  even  come  on  at  irregular  periods 
from  straining  or  physical  exercise.  The  amount  of  blood  lost  at  any 
particular  time  varies,  and  one  must  always  take  cum  grano  salis  the 
description  of  patients  as  to  the  quantity  or  extent  of  any  individual 
ha'morrhage. 

In  deciding  upon  the  source  of  bleeding  from  the  rectum,  one  must 
always  bear  in  mind  the  fact  that  it  may  come  from  the  stomach  or 
from  some  portion  of  the  upper  intestine.  Blood  from  the  upper  intes- 
tinal tract  will  be  decomposed,  dark,  and  tar-like  in  appearance;  it 
will  be  mixed  Avith  the  faeces  and  contain  inore  or  less  mucus.  That 
from  haemorrhoids  is  brighter  in  color,  not  mixed  with  f^ces,  but  gen- 
erally passes  after  the  f»cal  mass.  When  it  first  appears  it  may 
be  of  a  dark,  venous  character,  but  if  exposed  to  the  air  for  a  short 


HEMORRHOIDS— PILES  609 

time  it  will  become  brighter  in  color  b}'  the  absorption  of  oxygen.  The 
fact  that  the  blood  is  mixed  with  faeces  and  is  clotted  does  not  preclude 
the  possibility  of  its  coming  from  internal  haemorrhoids;  there  are 
patients  who,  from  time  to  time,  pass  from  the  rectum  large  masses 
of  clotted  blood  that  undoubtedly  came  from  internal  hasmorrhoids 
developed  high  up  on  the  upper  margin  of  the  internal  sphincter.  In 
all  such  cases  the  hemorrhages  cease  after  the  haemorrhoids  are 
removed. 

The  protrusion  of  internal  hemorrhoids  does  not  occur  until  after 
the  tumors  have  developed  considerable  size.  They  at  first  come  down 
only  a  very  short  distance  and  appear  to  the  patient  as  an  uncom- 
pleted stool,  a  sensation  of  something  more  to  come  away.  As  the 
condition  develops,  however,  this  increases,  and  the  patient  when  strain- 
ing at  stool  will  feel  at  the  margin  of  the  anus  one  or  more  little 
masses,  soft  and  velvety  to  the  touch  but  without  pain.  In  the  beginning 
they  recede  sj)ontaneously,  but  as  they  become  larger  and  prolapse  far- 
ther the  grasp  of  the  sphincter  obstructs  the  return  flow  of  blood  in  the 
tumors,  they  swell,  the  margin  of  the  anus  becomes  oedematous  (Plate 
IV,  Fig,  3),  and  the  patient  finds  it  necessary  to  reduce  them  by  firm 
pressure.  In  ordinary  cases  this  reduction  is  a  simple  and  easy  process, 
but  at  times  it  is  very  difficult.  "Wliere  there  is  great  hypertrophy  both 
of  the  vascular  and  connective  tissue,  the  reduction  is  sometimes  impos- 
sible to  the  patient  himself,  and  it  becomes  necessary  to  obtain  surgical 
assistance.  In  such  cases  rest  in  bed  with  the  hips  elevated  and  hot 
applications  will  sometimes  result  in  spontaneous  reduction. 

Ordinarily  there  is  no  pain  at  the  site  of  the  tumors,  but  in  well- 
developed  cases  there  is  a  constant  sensation  of  weight  and  aching  in 
the  sacral  region.  Sometimes  there  may  be  sharp  lancinating  pains 
around  the  margin  of  the  anus  when  the  hsemorrhoids  are  low  down 
and  wdthin  the  grasp  of  the  external  sphincter. 

^Tien  the  tumors  prolapse  and  there  is  strangulation  by  the 
sphincter  muscles,  the  pain  may  become  very  severe.  As  a  matter  of 
fact,  however,  the  longer  the  haemorrhoids  have  existed  and  the  greater 
the  prolapse  wdiich  accompanies  them,  the  more  relaxed  and  free  from 
spasm  will  the  sphincter  become.  Thus,  strangulation  in  old  cases  of 
haemorrhoids  or  in  patients  beyond  middle  life  is  rather  a  rare  occur- 
rence. It  occurs  more  frequently  in  acute  cases  in  which  inflamma- 
tion has  developed  and  in  patients  of  middle  age. 

Mucus  is  very  generally  present,  either  with  the  hemorrhages  or 
during"  their  intermissions.  Sometimes  after  bleeding  has  occurred 
periodically  for  a  long  time  it  ceases  altogether,  and  is  replaced  by  a 
constant  or  periodical  discharge  of  mucus  from  the  rectum;  this  is  the 
condition  which  Eichet  has  described  as  "white  hemorrhoids."  Ball 
39 


610  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

appropriately  says  of  this:  "  It  is  a  singularly  inappropriate  term  to 
designate  what  is  nothing  more  than  a  catarrhal  discharge  resulting 
from  continued  irritation  of  the  rectal  mucous  membrane." 

Kelsey  describes  as  one  of  the  symptoms  of  haemorrhoids  a  condi- 
tion which  he  terms  "  reetophobia — the  sense  of  impending  evil,  which 
is  so  common  in  rectal  troubles."  He  says:  "  There  is  hardly  any  variety 
of  pain  or  of  functional  nervous  disease  that  I  have  not  cured  by  the 
simple  removal  of  haemorrhoids,  and  this  applies  as  often  to  men  as 
to  women."  There  is  no  doubt  that  haemorrhoids  and  any  other  form 
of  rectal  irritation  may  produce  profound  impressions  upon  the  nervous 
system.  As  has  been  described  elsewhere  in  this  book,  delusions,  hal- 
lucinations, and  marked  mental  aberration  are  by  no  means  infre- 
quently the  result  of  rectal  disease.  Such  impressions,  however,  are 
more  rarely  produced  by  haemorrhoids  than  by  ulceration,  stricture, 
and  faecal  impaction. 

Among  the  symptoms  of  haemorrhoids  one  should  bear  in  mind  the 
reflex  disorders  of  the  digestive  organs,  pain  in  the  back  and  shooting 
down  the  legs,  constipation  due  to  the  fear  of  having  a  movement  lest 
a  hsemorrhage  be  brought  on,  and  anaemia  consequent  upon  the  loss 
of  blood. 

Capillary  or  Ncevoid  Hcemorrlioids. — In  Hamilton's  division  this 
variety  is  described  as  a  capillary  nsevus  of  the  rectum.  The  facts 
that  naevi  are  usually  considered  as  congenital  growths,  and  this  type 
of  haemorrhoids  is  never  found  in  children,  render  this  term  some- 
what inapplicable.  "  Capillary  "  is  more  appropriate,  inasmuch  as  it 
describes  the  anatomical  condition.  They  consist  in  small,  raspberry- 
like developments  of  the  arterial  capillaries  close  to  the  surface  of  the 
mucous  membrane  of  the  rectum.  They  are  covered  by  a  very  thin 
layer  of  epithelium  which  is  easily  ruptured,  and  are  the  source  of 
very  frequent  haemorrhages. 

They  do  not  protrude,  and  can  not  be  located  by  the  most  delicate 
touch;  they  constitute  what  is  commonly  known  as  "  blind  bleeding 
piles";  they  bleed  upon  the  slightest  contact  with  an  instrument  or 
even  from  digital  examination.  The  blood  is  of  a  bright-red  arterial 
nature,  and  comes  as  a  sort  of  oozing  or  dripping  after  each  defeca- 
tion. The  amount  lost  at  any  one  time  is  never  very  great,  but  the 
frequent  recurrence  soon  depletes  the  system  and  brings  on  marked 
anaemia.  In  1  case  death  was  imminent  from  this  cause  when  the  pile 
was  removed  and  the  patient  cured  (Kelsey).  Under  the  microscope 
they  resemble  the  congenital  capillary  naevus,  and  from  this  the  term 
"  naevoid  "  has  arisen. 

When  they  have  existed  for  some  time  the  mucous  membrane  be- 
comes thickened  and  the  haemorrhages  cease,  but  the  tumor  continues 


HEMORRHOIDS— PILES 


611 


to  grow,  the  venous  and  connective-tissue  elements  increasing  more 
rapidly  than  the  arterial,  and  eventually  they  resolve  themselves  into 
venous  or  varicose  haemorrhoids. 

Pathology. — Macroscopically  they  present  a  soft,  velvety,  bright-red 
appearance  much  resembling  a  raspberry,  are  slightly  elevated  above 
the  mucous  surface,  and  covered  with  a  thin  layer  of  epithelial  cells. 
Ball  says  that  the  change  in  the  mucous  membrane  may  occur,  without 
any  other  manifestation  of  disease,  in  patches  as  big  as  a  sixpenny 
piece. 

Pressure  with  the  finger  will  cause  them  to  disappear  for  the  mo- 
ment, but  immediately  it  is  removed  the  tumor  recurs.  Ulceration 
does  not  result  from  the  bleeding,  and  consequently  there  are  no  cica- 
trices as  in  the  varicose  variety.  Under  the  microscope  they  present 
the  appearance  of  a  conglomeration  of  arterial  capillaries  cut  trans- 
versely and  at  difEerent  angles.  The  veins  are  few  and  the  connective- 
tissue  stroma  almost  entirely  absent.  They  are  covered  by  a  very 
thin  mucous  membrane;  sometimes  only  a  layer  of  striated  epithelium 
separates  them  from  the  intestinal  cavity. 

Mixed  Hcemorrhoids. — In  cases  where  internal  and  external  haemor- 
rhoids exist  together,  the  division  between  the  two  is  clearly  demarcated 
by  the  so-called  "  white  line  " 
of  Hilton,  or  sulcus,  which 
marks  the  attachment  of  the 
external  sphincter  to  the  lower 
end  of  the  gut. 

The  connective  tissue  is 
denser  at  this  point  than  else- 
where around  the  rectum,  the 
mucous  membrane  is  more 
closely  adherent  to  the  muscu- 
lar walls,  and  the  vascular  sup- 
ply is  most  limited.  It  is  only 
after  internal  haemorrhoids 
have  existed  for  some  time, 
and  through  their  gradual 
growth  and  downward  pressure 
have  raised  the  membrane  from 
its  close  attachment  to  the  mus- 
cle and  dilated  the  latter,  that 

the  piles  cover  this  line.  When  they  have  once  passed  it,  free  anastomosis 
with  the  veins  below  occurs,  and  we  have  what  is  called  externo-internal 
or  mixed  haemorrhoids.  They  are  covered  by  both  mucous  and  muco- 
cutaneous tissue   (Fig.   194),  and  are  composed  of  varicosities  of  the 


Fig.  194. — Mixed  ILemorrhoiu. 


612  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

internal  and  external  liannorrhoidal  veins;  they  are  of  a  pale  opaque 
pink  in  their  lower  portions  and  bright  red  or  purple  in  the  upper. 
They  are  smooth  and  globular  in  form  below  and  lobular  or  grooved 
above  like  varicose  hemorrhoids.  They  never  entirely  recede  into  the 
rectum,  inasmuch  as  part  of  them  belongs  outside.  Their  symptoms, 
pathology,  and  treatment  comprise  those  of  external  and  internal  haem- 
orrhoids combined. 

Treatment  of  Internal  H^moerhoids. — The  treatment  of  in- 
ternal haemorrhoids  may  be  classified  as  preventive,  palliative,  and  cura- 
tive. 

Preventive. — The  presence  of  predisposing  causes  may  be  recognized 
frequently  before  the  actual  development  of  haemorrhoids,  and  it  is 
the  part  of  the  family  physician  to  warn  his  patients  of  them.  The 
influence  of  heredity  is  very  problematical,  but  the  habits,  environ- 
ments, and  avocations  of  families  are  inherited,  and  they  cause  haemor- 
rhoids. 

Constipation  in  children  should  always  be  looked  upon  seriously 
and  its  causes  removed.  Dilatation  of  the  sphincter  will  often  accom- 
plish wonders  in  this  respect.  Cold  enemata,  soap  bougies,  and 
glycerin  suppositories  are  all  superior  to  the  use  of  laxatives  at  this 
age.  At  puberty  and  middle  age,  individuals  with  a  haemorrhoidal 
tendency  should  avoid  indiscretions  in  diet  such  as  would  cause  con- 
gestion of  the  liver,  constipation,  and  indigestion. 

The  avoidance  of  predisposing  and  exciting  causes,  such  as  sitting 
long  at  stool,  great  muscular  strain,  excessive  venery,  improper  diet 
and  drink,  will  do  much  to  prevent  the  disease.  A  meat  or  nitrogenous 
diet  is  the  most  effective  in  such  cases.  Wines,  liquors,  and  the  excessive 
use  of  tobacco  should  be  discountenanced. 

The  bowels  should  be  regulated,  but  not  by  drastic  or  irritating 
cathartics;  small  cold  enemata  at  regular  periods  is  very  effectual  for 
this  purpose,  and  they  also  tend  to  reduce  any  congestion  in  the  lower 
end  of  the  rectum.  Cascara  combined  with  malt  is  one  of  the  best 
laxatives  in  such  conditions,  and  should  be  administered  in  doses  rang- 
ing from  a  dram  to  an  ounce  at  bedtime,  according  to  the  patient's 
needs.  Phosphate  of  soda  is  also  an  excellent  remedy.  The  passage  of 
a  medium-sized  bougie  to  gently  dilate  the  sphincter  and  at  the  same 
time  stimulate  peristaltic  action  will  often  do  much  to  prevent  the 
disease.  This  should  not  be  done  too  frequently,  and  the  instrument 
should  not  be  too  large  lest  it  should  set  up  irritation  and  bring  on 
inflammation.  Once  in  twenty-four  or  forty-eight  hours  is  sufficient. 
Such  diseases  as  proctitis,  hepatitis,  uterine  displacements,  stricture 
of  the  urethra,  and  stone  in  the  bladder  should  be  remedied,  both 
on  account  of  their  effects  and  to  obviate  the  haemorrhoidal  develop- 


HEMORRHOIDS— PILES  613 

ment.  If  the  rectum  is  dry  and  the  faecal  masses  hard,  injections  of 
sweet-oil,  or  glycerin,  or  liquid  vaseline  will  prove  of  the  greatest 
benefit.  Even  where  the  haemorrhoids  have  already  begun,  these  sim- 
ple measures  directed  toward  the  rectum  itself,  and  the  avoidance  of 
habits  and  conditions  which  predispose  to  and  excite  the  hsemorrhoidal 
disease,  will  in  many  instances  abort  the  attack  and  prevent  its  future 
development. 

Palliative  Treatment. — Any  resort  to  tentative  or  palliative  measures 
in  conditions  which  may  be  radically  cured  by  operations,  little  if  at 
all  dangerous,  is  not  considered  conservative  surgery  to-day.  There 
are  many  patients,  however,  in  whom  radical  measures  are  out  of  the 
question  on  account  of  complicating  circumstances  and  diseases.  Physi- 
cal and  nervous  conditions,  business  and  social  arrangements,  and  some- 
times the  absolute  lack  of  moral  courage,  frequently  render  it  impossible 
or  unadvisable  to  operate  for  hasmorrhoids.  Some  hold  that  the  pallia- 
tion of  hemorrhoids  is  unscientific  and  only  done  from  sordid  motives; 
that  radical  removal  is  the  only  method  of  treatment.  Aside  from 
the  fact  that  operation  is  often  contraindicated,  the  patient  himself 
has  some  right  to  choose  whether  he  will  be  operated  on  or  treated  by 
palliative  means  for  conditions  in  which  life  is  not  endangered.  It  is 
true  that  hasmorrhoids  are  likely  to  recur  after  palliative  treatment, 
but  it  is  also  true  that  many  patients  treated  by  these  methods  go 
for  years  without  any  recurrence,  and  some  never  have  it.  The  fact 
that  the  large  majority  of  those  who  suffer  from  rectal  diseases  in  the 
United  States  to-day  are  treated  by  irregular  practitioners  is  due  to 
the  inability  or  refusal  of  the  general  surgeon  to  apply  palliative  meas- 
ures properly. 

If  the  disease  were  a  malignant  one,  or  one  likely  to  endanger 
the  life  or  usefulness  of  the  individual,  such  refusals  would  be  justi- 
fied; but  this  is  not  the  case.  Men  and  women  go  through  life,  live 
to  a  good  old  age,  and  die  from  some  other  disease,  carrying  with 
them  from  adolescence  a  bunch  of  haemorrhoids  that  become  aggravated 
from  time  to  time,  bleed  and  prolapse,  and  yet  never  disable  them  for 
more  than  short  periods.  Where  the  haem.orrhage  is  excessive  and  fre- 
quently repeated,  and  as  a  result  the  patient  is  weak,  debilitated,  and 
threatened  with  profound  anaemia,  a  radical  operation  is  demanded, 
and  one  may  be  justified  under  these  circumstances  in  refusing  to  take 
the  responsibility  of  doing  anything  else  than  radically  and  rapidly 
putting  an  end  to  this  exhaustive  drain  upon  the  system.  But  in  ordi- 
nary cases  of  simple,  varicose,  internal  haemorrhoids,  bleeding  occa- 
sionally, prolapsing  to  a  slight  degree,  and  causing  their  victims  nothing 
more  than  an  uneasiness  and  slight  discomfort,  the  palliative  method 
is  not  only  justifiable  but  frequently  the  most  advisable.     No  operative 


614  THE   ANUS,   RECTUM,   AND   PELVIC  COLON 

method  is  without  some  immediate  or  remote  danger;  therefore,  while 
a  patient  may  be  told  that  there  is  practically  no  danger  to  his  life, 
there  is  always  the  possibility  of  results  which  are  altogether  unde- 
sirable. Of  course  such  results  are  very  improbable,  but  they  do  occur, 
and  patients  hearing  of  them  become  unalterably  opposed  to  operative 
treatment.  With  nervous  patients  such  a  conviction  is  a  contraindica- 
tion to  operative  procedures,  and  the  radical  methods  have  been  fre- 
quently brought  into  disrepute  by  being  forced  upon  such  individuals 
who  suffer  from  imaginary  disabilities  and  discomfort  in  the  rectum 
forever  afterward.  In  cases,  therefore,  with  these  exaggerated  fears 
and  antipathies  toward  operative  procedure,  it  is  better  to  adopt  the 
palliating  methods,  explaining  thoroughly  that  they  are  not  radical 
cures,  but  that  by  repetition  they  will  give  relief  and  maintain  compara- 
tive comfort  as  long  as  they  are  continued. 

The  cardinal  principles  in  the  palliative  treatment  of  haemorrhoids 
consist  in  the  prevention  of  prolapse  and  arrest  of  ha?morrhage.  The 
hagmorrhage  is  always  the  most  alarming  symptom  to  the  patient,  and 
as  it  may  be  excessive  it  should  be  considered  first.  It  is  rarely  diffi- 
cult to  stop  the  flow;  rest  in  the  horizontal  position,  cold  applications, 
injections  of  hydrastis,  tannic  acid  and  krameria,  and  pressure  upon 
the  anus  will  usually  accomplish  this.  The  chief  object  is  to  prevent 
its  recurrence.  In  the  first  place,  obstructions  to  the  portal  circula- 
tion should  be  remedied  at  once,  whether  they  be  in  the  line  of  the 
vessels  or  in  the  liver  itself.  The  diet  should  be  regulated  as  to  quality 
and  quantity.  Less  food  and  more  exercise  is  usually  good  advice  in 
these  cases,  but  there  are  ex'ceptions  to  this  rule.  Restriction  in  the 
use  of  carbohydrates  and  alcohol  is  always  necessarv.  If  the  patient 
has  been  in  the  habit  of  taking  a  large  quantity  of  liquor,  and  it  is 
impossible  or  unadvisable  to  cut  it  off  altogether,  a  small  glass  of 
sherry  or  a  little  Scotch  or  rye  whisky  two  or  three  times  a  day  may 
be  allowed.  Coffee  and  tea  should  be  taken  in  great  moderation,  and 
the  use  of  tobacco  should  be  limited. 

He  should  also  be  directed  to  take  regular  and  prolonged  exercise 
in  the  open  air.  If  the  haemorrhoids  do  not  prolapse  so  that  they  would 
be  irritated  by  horseback-riding,  it  is  one  of  the  best  forms  of  exercise 
for  stout  individuals.  Sometimes,  however,  the  separation  of  the  but- 
tocks in  order  to  straddle  a  horse,  and  the  strain  of  rising  and  falling 
in  the  stirrups,  induces  prolapse  of  the  tumors.  Under  such  circum- 
stances riding  is  harmful,  and  should  be  supplanted  by  walking  and 
moderate  indulgence  in  outdoor  athletics.  Late  hours  and  exhausting 
cares,  either  of  a  business  or  social  nature,  should  be  avoided.  A  regu- 
lar time  for  going  to  bed  and  rising  should  be  adopted,  but  too  much 
sleep  and  rest  in  bed  are  not  conducive  to  the  best  feeling  of  such 


HEMORRHOIDS— PILES  615 

patients.  Eight  hours  is  as  much  sleep  as  most  healthy  individuals 
need,  and  rising  at  a  moderate  hour  after  this  amount  of  rest,  together 
with  a  cool  bath  and  a  good  rub,  is  much  more  conducive  to  good  feeling 
and  general  functional  activity  than  lying  in  bed  covered  and  over- 
heated for  nine  or  ten  hours.  The  regulation  of  the  bowels  is  of  great 
importance;  the  fgecal  masses  should  be  kept  soft  and  unirritating,  and 
abdominal  straining  at  stool  prevented.  A  certain  amount  of  laxative 
medicine  is  necessary  in  the  treatment  of  all  these  cases,  especially  in 
the  beginning.  Some  remedy  which  will  produce  a  soft,  consistent 
stool  is  therefore  better  than  cholagogues  or  saline  purgatives.  The 
following  combination  is  excellent: 

R  Ext.  colocynth  comp.,  )  __  .. 

„  ,  y aa  gr.  xn: 

Ext.  cascara;,  j  o         j^ 

Ext.  belladonnse,    )  __  ... 

-^  ,  .        y aa  gr.  111. 

Ext.  nux  vomicae,  j 

M.    Ft.  pil.  No.  xii. 

Sig. :  One  or  two  at  bedtime. 

Cascara  given  as  heretofore  advised  is  very  satisfactory.  Aloin, 
gamboge,  and  the  resinous  cathartics  are  often  harmful  in  this  condi- 
tion, but  occasionally  a  combination  of  calomel,  bicarbonate  of  soda, 
and  podophyllin  in  small  doses  two  or  three  times  a  day  for  a  week  will 
act  like  magic.  Phosphate  of  soda  or  small  doses  of  Eochelle  salts  in  "hot 
water  before  breakfast  are  also  very  effectual  at  times.  Cold-water  ene- 
mata  are  often  more  satisfactory  than  drugs.  Any  preparation  which 
produces  straining  and  prolonged  sitting  at  stool  should  be  at  once 
discontinued.  After  the  bowels  have  moved  the  parts  should  be  gently 
cleansed  with  cold  water  and  a  soft  sponge,  but  never  wiped  vigorously 
with  rough  or  irritating  detergent  material,  especially  newspaper,  as 
printers'  ink  is  very  deleterious  in  this  condition. 

If  the  haemorrhoids  prolapse  and  spontaneously  recede,  great  bene- 
fit may  be  derived  from  lying  down  and  injecting  a  small  quantity 
of  cold,  even  ice-water,  into  the  rectum  immediately  after  the  move- 
ment of  the  bowels,  and  retaining  it  as  long  as  possible.  If,  however, 
they  have  to  be  replaced,  it  is  a  good  plan  to  cleanse  them  as  above 
advised,  and  before  reducing  apply  some  astringent  ointment  or  solu- 
tion. The  following  formula  of  the  late  Dr.  Cathcart,  of  Philadelphia, 
is  excellent  for  this  purpose: 

1^  Ung.  acid,  tannici oiv; 

TJng.  stramonii,      ]      ._  ^^.^ 

Ung.  belladonnse,  j 
M.    Ft.  unguentum. 


616  TPIE   ANUS,   RECTUM,  AND   PELVIC   COLON 

This  ointment,  aijplicd  freely  at  the  time  of  stool  and  upon  going 
to  bed  at  night,  will  not  only  eheck  moderate  luiMnorrhages  but  subdue 
the  active  iniiammation  in  the  luumorrhoids.  Even  where  haemorrhoids 
are  inflamed  and  partially  strangulated  by  inflammation,  its  applica- 
tion will  frequently  subdue  the  condition  to  such  an  extent  within  a 
few  hours  that  the  patient  wall  rarely  consider  the  question  of  opera- 
tion  when   he   realizes   the   relief   obtainable   from   such   methods   of 


Fig.  195. — Hard-rubber  I'ile-pipe. 

treatment.  Where  the  haemorrhoids  do  not  protrude,  the  applica- 
tion of  the  ointment  may  be  made  through  a  hard-rubber  pile-pipe 
(Fig.  195). 

Another  ointment  which  is  popular  in  the  markets,  and  said  to  be 
of  great  value  in  the  treatment  of  hajmorrhoids,  is  the  following: 

^   Sulph.  morphiaj gr.      1^; 

Tannin    gr.    24; 

Pine-tree  tar   gr.    36; 

Wax gr.    36; 

Benzoated  lard gr.  383. 

Fluid  extract  of  wich-hazel  is  also  a  useful  remedy  in  internal  haem- 
orrhoids. For  immediate  control  of  hemorrhage  most  authors  recom- 
mend the  application  of  persulphate  or  perchloride  of  iron;  it  produces 
a  clot  which  is  very  hard  and  irritating  to  the  mucous  membrane,  and 
is  frequently  followed  by  a  secondary  haBmorrhage  when  this  comes 
away.  The  reduction  of  the  haemorrhoidal  mass  and  the  injection  of 
cold  water,  or  the  application  to  the  tumor  of  a  pledget  of  cotton  thor- 
oughly infiltrated  with  iodoform  or  suprarenal  extract,  will  check  the 
hemorrhage  quite  as  well  and  does  not  leave  any  uncomfortable  after- 
effects. The  latter  promises  to  become  the  most  reliable  remedy  for 
this  purpose.  Where  the  hemorrhoids  do  not  protrude  it  may  be  used 
in  suppositories  as  follows: 

J^   Ext.  suprarenalis   gr.  x ; 

01.  theobrome   gr.  xl. 

These  can  be  applied  immediately  after  stool  and  upon  going  to 
bed;  they  produce  no  irritation  of  the  mucous  membrane  and  no  uncom- 
fortable effects  whatever.    In  cases  where  there  is  excoriation  or  ulcera- 


HEMORRHOIDS— PILES  61Y 

tion  of  the  lia^morrhoidal  tumor,  powders  such  as  bismuth,  calomel,  oxide 
of  zinc,  and  aristol  serve  the  double  purpose  of  checking  hgemorrhage 
and  healing  the  parts. 

Suppositories  are  sometimes  a  convenient  method  to  apply  drugs 
to  hemorrhoids,  but  they  frequently  slip  up  beyond  the  diseased  area 
and  do  no  good.  Kecently  some  have  been  put  upon  the  market  so 
shaped  that  they  remain  in  the  hsemorrhoidal  area  until  they  are  dis- 
solved. Iodoform  in  quantities  of  5  to  10  grains  in  each  suppository 
sometimes  gives  much  relief. 

Ichthyol  in  combination  with  other  drugs  is  an  excellent  remedy. 
The  following  formula  is  very  effective: 

I^   Ichthyol,         I 

Tannic  acid,  j 8  •  '^^ 

Ext.  belladonna,  ) 

Ext.  stramonii,       i   "  ' ' '   &  •  t  j 

Ext.  hamamelis , gr.  x. 

M.    Ft.  suppository. 

Opium  in  any  form  is  rarely  useful  in  the  treatment  of  hemor- 
rhoids because  it  causes  constipation.  The  hypodermic  use  of  morphine 
is  admissible  where  the  pain  is  very  great  and  where  spasm  of  the 
sphincter  is  annoying.  This  spasm  of  the  sphincter  is  a  matt-er  of 
considerable  importance  in  the  palliative  treatment  of  haemorrhoids. 
The  occasional  passage  of  a  full-sized  rectal  bougie,  which  is  allowed 
to  remain  within  the  grasp  of  the  sphincter  for  five  or  ten  minutes, 
usually  overcomes  the  spasm,  but  occasionally  it  is  necessary  to  admin- 
ister nitrous  oxide  or  ethyl  chloride  and  divulse  the  muscle.  Patients 
submit  to  this  who  will  not  consider  other  operations  at  all,  and  it 
sometimes  results  in  radical  cure. 

The  amount  of  relief  that  can  be  obtained  and  the  number  of  cases 
which  can  be  practically  cured  through  these  palliative  methods  are 
not  appreciated  by  surgeons  and  practitioners  in  general.  Thousands 
of  patients  who  have  hEemorrhoidal  disease  are  yearly  consulting  irregu- 
lar practitioners  and  quacks  for  non-operative  treatment  of  these  condi- 
tions. It  is  useless  to  say  that  these  "  pile  doctors  "  do  not  cure  any- 
body. In  a  given  number  of  cases  their  methods  would  not  be  as  uni- 
formly successful  as  operative  measures;  nevertheless,  they  would  suc- 
ceed in  relieving  the  large  majority  and  in  practically  curing  many  of 
them.  It  is  wise,  therefore,  not  to  force  an  operation  upon  unwilling 
patients,  but  to  give  them  the  benefit  of  whatever  knowledge  is  pos- 
sessed of  this  line  of  treatment.  Frequently,  if  they  have  been  re- 
lieved in  several  attacks  of  hemorrhoids  by  palliative  measures  only 
to  have  recurrences,  it  will  be  possible  to  overcome  their  prejudices 


618  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

and  persuade  them  to  have  radical  operations  done,  although  they  at 
first  absolutely  refused  to  do  so. 

Operative  Treatment  of  Ilannorrhoids. — Of  the  many  operations  de- 
vised for  the  cure  of  internal  hannorrhoids  only  a  few  need  be  described 
at  the  present  day.  They  are  all  based  upon  one  of  two  principles, 
viz.,  the  atrophy  of  the  tumors  by  shutting  off  their  blood  supply,  or 
their  radical  removal  by  surgical  operations.  The  principal  methods 
of  accomplishing  these  ends  are  gradual  or  forcible  dilatation  of  the 
sphincter,  cauterization,  injection,  the  ligature,  clamp  and  cautery, 
crushing,  excision. 

Dilatation. — In  the  foregoing  pages  we  have  already  referred  to  the 
beneficial  effects  of  gradual  dilatation  in  the  treatment  of  minor  degrees 
of  hemorrhoids.  Yerneuil  was  the  first  advocate  of  this  method,  and 
in  1871  published  an  article  in  which  he  claimed  that  the  use  of  cold 
water,  and  either  gradual  or  rapid  dilatation  of  the  sphincter  muscles, 
were  the  best  methods  for  the  cure  of  this  disease.  The  fact  that  acute 
internal  hasmorrhoids  existing  in  women  during  pregnancy  are  often 
relieved  or  cured  by  dilatation  of  the  sphincter  at  the  time  of  delivery, 
is  well  known;  but  it  is  impossible  to  understand  how  this  operation  can 
accomplish  any  good  in  old  cases  wdiich  prolapse  at  stool  or  upon  the 
slightest  provocation,  and  in  which  the  muscles  are  already  too  relaxed 
to  retain  the  parts  in  their  normal  position.  Further  dilatation  in 
such  cases  would  only  aggravate  the  condition.  In  this  class  of  cases 
it  is  not  only  necessary  to  get  rid  of  the  tumors,  but  also  to  restore  the 
tone  of  the  sphincter  muscles. 

On  the  other  hand,  there  are  mild  cases  of  the  disease  in  which  the 
small  tumors  prolapse  at  stool  and  are  grasped  by  the  external  sphincter, 
thus  causing  much  pain  and  annoyance.  In  these,  divulsion  often  re- 
lieves the  symptoms,  and  if  it  is  followed  by  cold  injections  and  proper 
regimen,  it  will  result  in  a  radical  cure.  Dilatation  can  be  easily  per- 
formed under  the  influence  of  nitrous  oxide  gas  or  ethyl  chloride;  the 
operation  does  not  disable  the  patient  in  the  least,  and  may  be  done  in 
the  doctor's  office  without  any  fear  of  bad  results.  The  permanency  of 
cure  by  this  method  depends  largely  upon  the  faithfulness  with  which 
the  cold  enemata  and  dietary  regimen  are  carried  out  afterward. 

Method  of  Dilatation. — Inasmuch  as  dilatation  of  the  sphincter  forms 
an  integral  part  of  all  radical  operations  for  hemorrhoidal  disease,  it 
seems  worth  while  to  give  the  subject  a  somewhat  detailed  description. 
Numerous  instruments  and  methods  have  been  devised  by  different  oper- 
ators to  accomplish  this  purpose;  most  of  them  are  practically  divulsors, 
but  they  may  be  used  as  dilators  instead.  The  principle  which  underlies 
all  true  benefit  from  dilatation  consists  in  the  fact  that  the  muscles  are 
not  torn  but  simply  overstretched  till  all  spasm  is  overcome.     "Where 


HEMORRHOIDS— PILES  619 

the  dilatation  is  carried  on  too  rapidly,  the  mucous  membrane  is  torn 
and  the  muscular  fibers  are  separated  at  the  anterior  and  posterior  com- 
missures. When  this  takes  place  the  muscles  themselves  are  only  par- 
tially stretched  and  soon  resume  their  spasmodic  condition,  which  is  only 
exaggerated  by  the  fissure-like  cleft  which  is  made  in  the  mucous  mem- 
brane. If,  however,  the  dilatation  is  gently  and  slowly  carried  out  the 
muscles  may  be  stretched  and  temporarily  paralyzed  without  any  tear  of 
the  mucous  membrane,  except  in  cases  where  fissures  or  ulceration  al- 
ready exist,  and  the  results  will  be  much  more  permanent  in  the  relief 
of  the  spasm.  Kelly's  anal  dilator  (Fig.  68,  d)  is  a  iiseful  instrument  for 
the  accomplishment  of  this  purpose.  It  is  supplied  with  a  register  which 
gives  the  operator  a  full  knowledge  of  the  amount  of  dilatation  accom- 
plished; it  should  be  introduced  with  a  boring  motion,  being  withdrawn 
occasionally  for  the  operator  to  test  by  digital  touch  the  amount  of 
relaxation  accomplished  in  the  muscles.  Four  or  five  minutes  should 
be  occupied  in  this  method  of  dilatation,  and,  speaking  in  general  terms, 
it  should  be  carried  out  until  four  fingers  can  be  easily  introduced 
through  the  anus  and  into  the  ampulla  of  the  rectum.  By  it  all  parts  of 
the  anus  are  distended  equably,  and  little  danger  of  rupture  exists. 

Another  instrument  which  is  highly  recommended  for  this  purpose  is 
Mathews's  rectal  divulsor  (Fig.  196).  The  skilful  hand,  however,  is 
better  than  any  instrument  for  this  purpose.    There  are  two  principal 


'VyA 


C 
Fi&.  196. — Mathews's  Eectal  Divulsor. 


methods  in  vogue  for  manual  dilatation  of  the  sphincters:  in  the  first 
the  two  thumbs  are  introduced  through  the  anus  and  slowly  but  firmly 
separated  from  before  backward  and  then  from  side  to  side,  practising 
massage  upon  the  resisting  muscles  until  a  flabby,  pulp-like  condition 
is  produced.  The  time  occupied  by  this  procedure  will  differ  according 
to  the  development  and  spasm  of  the  muscles;  in  some  cases  it  can  be 
easily  done  in  two  minutes  and  with  very  little  force;  in  otliers,  it 
requires  five  to  six  minutes  and  all  the  strength  that  the  operator  pos- 
sesses in  his  thumbs.  The  tendency  is  always  toward  too  great  haste. 
If  carefully  performed,  it  can  be  done  without  rupturing  the  mucous 
membrane  or  causing  bleeding,  but  there  will  always  follow  it  a  certain 
amount  of  extravasation  of  blood  in  the  cellular  tissue  around  the  anus. 
The  habit  of  putting  the  thumbs  in  the  rectum  and  the  fingers  of  one 
hand  upon  the  pubis  and  those  of  the  other  upon  the  sacrum,  or  upon 


620  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

the  tuber  iscliii,  and  stretching  or  tearing  the  reeturn  in  ten  or  fifteen 
seconds  to  the  desired  extent,  is  unsurgieal  and  often  disastrous;  deliber- 
ation and  patience  in  the  performance  of  this  operation  can  not  be  in- 
sisted upon  too  strongly.  One  should  also  be  careful  in  stretching  the 
rectum  from  before  backward  not  to  press  upon  the  prostate  or  crush 
the  urethra  against  the  pubis,  thus  producing  traumatism  of  these 
organs;  sometimes  irritation  of  the  neck  of  the  bladder  and  deep  urethra, 
together  with  more  or  less  bleeding  from  the  urethra,  follow  violent 
dilatation  of  the  rectum  in  this  direction.  The  second  method  of  dilata- 
tion consists  in  introducing  one  finger  after  another  into  the  anus  until 
all  four  can  be  insinuated  through  the  two  sphincters;  this  is  done  with 
a  boring  motion,  and  finally  the  body  of  the  hand  can  be  inserted.  With 
the  fingers  and  palm  of  the  hand  passed  through  the  sphincter  muscle, 
the  former  are  then  doubled  up,  as  in  closing  one's  fist,  and  further  dila- 
tation thus  occurs  through  the  expansion  of  the  circumference  of  the 
hand.  Care  should  be  taken  that  the  finger-nails  are  always  short  and 
clipped  round,  so  that  cutting  or  scratching  of  the  mucous  membrane 
will  be  avoided.  The  same  time  and  deliberation  should  be  exercised 
in  this  method  as  in  those  previously  described.  This  method  of  dila- 
tation is  that  employed  in  Simon's  operation  of  introducing  the  hand 
into  the  rectum  for  the  purposes  of  examination.  If  equal  care  and 
deliberation  are  exercised,  one  of  these  methods  is  just  as  good  as  the 
other. 

Before  attempting  any  operation,  or  allowing  the  patient  to  come  out 
from  under  the  influence  of  the  ana-sthetic,  the  operator  should  remove 
the  dilating  instrument  or  his  hand  for  two  or  three  minutes,  to  observe 
whether  or  not  there  is  a  tendency  in  the  muscle  to  recontract.  In  case 
such  a  condition  exists,  he  should  carry  the  dilatation  farther  and  retain 
the  dilating  instrument  or  hand  for  a  longer  time.  Thorough  relaxation 
having  been  accomplished,  one  may  proceed  with  whatever  operation  is 
necessary.  If  dilatation  is  all  that  is  intended,  a  suppository  containing 
opium  1  grain  and  extract  of  belladonna  |  grain  should  be  introduced, 
and  a  compress  of  soft  cotton  wool  applied  to  the  anus. 

Most  operators  advise  confining  the  patient  for  two  or  three  days 
after  this  operation.  Unless  there  be  some  haemorrhage  or  other  reason 
calling  for  this,  it  is  unnecessary. 

The  use  of  cocaine,  either  hypodermically  or  locally,  for  stretching 
the  sphincter  has  not  proved  satisfactory  in  my  hands;  the  amount  of 
the  drug  necessary,  the  frequent  punctures  of  the  needle  and  consequent 
irritation  and  oedema  of  the  parts,  are  all  objectionable.  Eeclus  and 
Bodine  have  each  reported  satisfactory  results  from  the  injection  of  large 
quantities  of  a  mild  solution  of  the  drug  for  this  ])urpose,  Init  in  general 
one  will  find  some  form  of  complete  ana3sthesia  much  more  satisfactory. 


HEMORRHOIDS—PILES  621 

Treatment  by  Cauterization. — Cusack  and  Houston  (Dublin  Jour,  of 
Med.  Sci.,  1843,  p.  95)  many  years  ago  enthusiastically  advocated  the  use 
of  nitric  acid  in  the  treatment  of  hsemorrhoids.  This  and  various  other 
cauteries  have  been  from  time  to  time  exploited  as  cures  for  this  disease. 
The  method  is  very  useful  in  the  capillary  variety  of  piles  but  it  has 
become  obsolete  in  all  others. 

In  capillary  haemorrhoids,  the  application  of  nitric  acid  is  one  of  the 
safest  and  most  elf cctive  means  of  treatment.  In  these  cases  a  conical 
speculum  (Fig.  63)  is  introduced,  and  the  slide  is  drawn  out  until  the 
little  pile  protrudes  into  the  fenestrum;  it  should  be  wiped  off  dry  with 
absorbent  cotton,  and  the  acid  applied  all  over  its  surface  by  means  of  a 
wood  or  glass  applicator.  Some  have  advised  the  use  of  little  spun-glass 
brushes  for  the  application  of  the  acid,  but,  as  Ball  points  out,  there  is 
danger  of  small  fragments  of  glass  breaking  off  from  these  brushes  and 
penetrating  or  irritating  the  mucous  membrane.  The  speculum  should 
be  held  in  place  for  four  or  five  minutes  until  the  acid  has  thoroughly 
attacked  the  tumor,  and  then  the  parts  should  be  washed  off  with  a 
saturated  solution  of  bicarbonate  of  soda  in  order  to  remove  any  excess 
of  acid  which  may  remain.  The  first  application  of  the  acid  generally 
checks  the  bleeding  effectually,  but  in  order  to  eradicate  the  tumor  it  is 
necessary  to  repeat  the  application  two  or  three  times  at  intervals  of 
about  five  days  or  a  week. 

There  is  no  necessity  for  cocaine  or  any  other  local  anaesthetic  in  this 
method,  as  it  produces  no  pain  in  the  mucous  membrane;  but  great  care 
is  necessary  to  avoid  touching  the  margin  of  the  anus  with  the  acid. 
That  region  should  be  smeared  with  vaseline  before  the  application  is 
attempted.  After  the  speculum  is  withdrawn,  a  suppository  containing 
^  a  grain  of  opium  is  advisable  to  overcome  tenesmus  and  peristaltic 
action. 

Other  chemicals  have  been  employed  for  this  purpose,  such  as  nitrate 
of  silver,  caustic  potash,  arsenical  paste,  acid  nitrate  of  mercury,  pyro- 
gallic  acid,  and  butter  of  antimony,  but  none  of  these  is  as  effectual  as 
the  fuming  nitric  acid. 

Hamilton  (Ball",  op.  cit.,  p.  255)  recommends  passing  through  the  tu- 
mor needles  coated  with  fused  nitrate  of  silver.  A  better  method  than 
any  of  these,  however,  consists  in  the  application  of  the  electro-cautery. 
The  tumor  is  brought  into  view  just  as  for  the  application  of  nitric 
acid,  and  a  10-per-cent  solution  of  cocaine  applied  as  a  precaution  more 
than  a  necessity.  After  two  or  three  minutes  a  small,  flat  electro-cautery 
is  applied  to  the  summit  of  the  tumor  and  the  current  turned  on;  by  this 
the  whole  growth  can  be  burned  away  at  one  sitting;  the  hemorrhage 
is  immediately  checked  and  does  not  recur,  and  afterward  an  opium  sup- 
pository is  introduced  and  the  patient  is  allowed  to  go  about  his  occupa- 


622  THE  ANUS,   RECTUM,   AND   PELVIC  COLON 

tiou  after  two  or  three  liour.s'  rest.  Tliis  })roee(lure  has  the  advantages 
of  being  aseptic,  radical,  and  exact,  in  that  one  can  govern  absolutely 
the  area  and  depth  to  which  the  cautery  burns,  and  a  second  application 
is  rarely  necessary.  The  method  is  also  applicable  to  small  venous  piles 
high  up  in  the  rectum. 

Eleelroh/sis. — For  the  class  of  tumors  which  have  just  been  men- 
tioned, Ball  recommends  electrolysis.    His  method  is  as  follows: 

"  The  pile  being  brought  into  view,  the  surface  is  well  painted  over 
with  a  solution  of  cocaine  hydrochlorate  (4  per  cent),  and  after  the  lapse 
of  five  or  ten  minutes  four  or  five  round  sewing-needles  mounted  in  a 
handle  are  passed  into  the  center  of  the  tumor  and  connected  with  the 
negative  pole  of  the  battery,  10  to  20  Leclanche  elements  being  the  most 
suitable;  the  other  (positive)  pole  being  applied  by  means  of  a  wet  sponge 
to  the  buttock.  After  a  few  minutes  the  surface  of  the  pile  will  be  seen 
to  become  white,  and  minute  bubbles  of  hydrogen  gas  will  be  seen  es- 
caping round  the  needles.  As  soon  as  this  is  well  marked,  the  needles 
are  withdrawn,  and  if  deemed  necessary,  reintroduced  into  another  part 
of  the  same  or  another  pile.  In  a  few  days  the  piles  shrivel  up  and  dis- 
appear painlessly.  If  the  positive  pole  is  used  the  needles  stick  tightly 
in,  and  haemorrhage  may  result  from  their  forcible  withdrawal.  It  has, 
however,  in  order  to  avoid  this  inconvenience,  been  recommended  in  the 
case  of  nsevi  to  use  the  positive  pole  first  attached  to  the  needles,  and 
then,  after  a  few  minutes,  to  reverse  the  current  for  a  short  time  previous 
to  the  withdrawal  of  the  needles.  I  have  not,  however,  found  this  plan 
satisfactory,  and  prefer  to  use  the  negative  pole  all  through.''  It  re- 
quires one  or  two  applications  to  complete  the  cure,  it  does  not  confine 
the  patient,  and  with  the  use  of  cocaine  there  is  comparatively  no  pain. 
This  method  is  more  difficult  than  electro-cauterization,  and  the  results 
are  not  quite  so  radical.  The  one  advantage  which  it  has  over  the  other 
method  is  that  no  ulceration  is  produced  by  it,  and  the  patient  is  never 
annoyed  by  the  slight  moisture  and  occasional  backache  which  is  asso- 
ciated with  all  operations  which  depend  upon  healing  by  granulation. 

Injection  Method. — The  injection  treatment  of  htemorrhoids  is  said 
by  Andrews  (Rectal  and  Anal  Surgery,  p.  34)  to  have  originated  with 
Mitchell,  of  Clinton,  111.,  in  1871.  The  method  was  kept  secret  and 
rights  to  practise  it  in  certain  districts  were  sold  to  drug  clerks,  farm- 
ers, irregular  practitioners,  or  to  any  one  who  had  the  money  to  pay 
for  them.  It  soon  fell  into  the  hands  of  uneducated  and  irresponsible 
charlatans  who  traveled  from  town  to  town,  recklessly  performing  the 
operation  upon  all  kinds  of  cases,  sometimes  injecting  polypi  and 
even  carcinomata  for  piles.  Andrews's  statistics  upon  this  method 
were  gathered  from  the  work  of  this  class  of  practitioners,  and  the 
great  wonder  is,  not  that  he  found  many  bad  results,  but  that  they 


HEMORRHOIDS— PILES 


623 


were  so  few.     He  collected  3,30 J:  cases  (loc.  cit.,  p.  3G)  with  the  fol- 
lowing results: 


Deaths 13 

Embolism  of  liver 8 

Sudden  and  dangerous  jDrostration.  .  .     1 

Abscess  of  liver 1 

Dangerous  haemorrhage 10 

Permanent  impotence 1 


Stricture  of  the  rectum 2 

Violent  pain 83 

Carbolic -acid  poisoning 1 

Failed  to  cure 19 

Severe  inflammation 10 

Sloughing  and  other  accidents 35 


The  records  are  not  sufficiently  complete  for  analysis,  hut  it  is 
safe  to  say  that  they  show  remarkably  good  results  obtained  by  the 
method  under  adverse  circumstances.  Any  other  surgical  operation 
for  haemorrhoids  in  such  inexperienced  and  unscientific  hands  would 
have  produced  a  larger  mortality  and  a  longer  list  of  accidents.  The 
mortality  of  less  than  one-half  of  1  per  cent,  and  failures  in  about 
one-half  of  1  per  cent,  are  certainly  not  alarming  results.  Can  any 
practitioner  cite  3,300  cases  of  haemorrhoids  operated  by  any  other 
method  with  only  2  strictures?  The  other  accidents,  embolism  and 
abscess  of  the  liver,  prostration,  permanent  impotence,  carbolic-acid 
poisoning,  severe  inflammation  and  sloughing,  are  too  indefinite  and 
problematic  in  their  etiology  to  merit  a  discussion.  It  is  possible  some 
of  them  were  produced  by  the  injection,  but  certain  that  most  of  them 
were  not.  These  statistics,  however,  and  the  abandonment  of  the 
method  by  Kelsey — who,  having  had  over  two  hundred  perfectly  satis- 
factory results,  suddenly  turned  against  the  operation  after  one  or  two 
accidents — created  at  one  time  a  strong  prejudice  against  it.  Lately, 
however,  a  better  knowledge  of  the  method  and  the  class  of  cases  to 
which  it  is  applicable  have  led  many  surgeons  to  give  it  a  trial,  and  their 
reports  are  very  satisfactory.  The  method  is  well  worthy  of  thorough 
consideration. 

The  Class  of  Hcemorrlwids  in  ivliicli  Injection  may  he  Used. — The 
most  enthusiastic  advocates  of  this  method  no  longer  advise  it  in  any 
other  than  internal  piles.  Even  Agnew,  in  the  last  edition  of  his  book, 
says:  "Since  the  advantages  of  cocaine  have  become  known,  and  the 
fear  of  hemorrhage  has  been  dispelled,  there  is  absolutely  no  apology 
for  the  treatment  of  external  hsemorrhoids  by  any  method  other  than 
excision"  (loc.  cit.,  p.  24).  This  is  the  position  taken  by  the  writer 
in  a  paper  before  the  Academy  of  Medicine  in  1894,  and  is  almost  uni- 
versally accepted."  Only  those  piles  should  be  injected  which  can  be 
brought  into  view  and  made  surgically  clean;  occasionally  small  tumors 
may  be  treated  through  the  conical  fenestrated  speculum,  but  it  is  not 
so  satisfactory  as  when  they  are  brought  outside  of  the  anus. 

The  size  of  the  haemorrhoids  is  no  contraindication  to  this  method 
of  treatment  so  long  as  they  completely  collapse  when  pushed  up  in 


624  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

the  rectum.  Some  claim  that  it  is  a  matter  of  inditrerence  whether 
the  h^emorrhoid  is  already  ulcerating  or  not,  but  the  author  does  not 
consider  it  wise  to  inject  under  these  circumstances.  Mixed  haemor- 
rhoids and  those  complicated  by  fissure  or  spasmodic  sphincter  are 
not  favorable  for  the  injection  treatment.  In  a  word,  uncomplicated, 
varicose,  internal  hemorrhoids  are  the  ones  to  which  this  method  is 
most  applicable. 

There  are  two  distinct  schools  in  the  injection  treatment:  the  first 
injects  strong  solutions  in  large  quantities,  thus  causing  a  sloughing 
of  the  entire  haemorrhoidal  tumor;  the  second  injects  small  quantities 
of  weak  or  moderately  strong  solutions,  and  in  this  way  produces  an 
inflammatory  induration  and  choking  of  the  circulation,  which  is  fol- 
lowed by  shrinking  and  atrophy  of  the  piles  without  ulceration  or 
sloughing. 

Agnew,  of  San  Francisco,  represents  the  first  school.  He  claims 
that  all  the  accidents  following  treatment  by  injection  are  due  to  the 
use  of  mild  solutions,  which  he  says  set  up  an  inflammatory  condition 
with  minute  thrombi  in  the  veins  that  are  easily  dislodged.  He  states 
that  the  injection  of  strong  solutions  of  carbolic  acid  in  quantities 
sufficient  to  permeate  the  entire  substance  of  the  tumor  acts  as  an 
escharotic,  causing  immediate  death  of  the  hfemorrhoidal  mass,  and 
this  drops  away  as  a  dry  eschar  in  a  few  days.  He  lays  great  stress 
upon  the  mixture  used,  which  he  prepares  as  follows: 

"  The  solution  of  carbolic  acid  found  to  be  uniformly  successful 
in  the  treatment  of  hemorrhoids  by  injection  is  prepared  by  first  mak- 
ing a  solution  of  the  acetate  of  lead  and  borax  in  glycerin,  in  the 
proportion  of  2  drams  each  of  the  chemically  pure  salts  to  1  ounce  of 
Price's  glycerin. 

R  Plumbi  acet.,  )  __  ^.. 

„    T .  1  -1  - aa  oil : 

Sodii  bibor.,    j  •" 

Glycerine 5j- 

"  Mix  in  a  graduate,  pour  into  a  2-ounce  vial,  and  let  stand  for  twenty- 
four  hours.  The  solution  of  the  salts  is  hastened  by  placing  the  vial 
in  a  warm-water  bath  and  letting  it  remain  there  for  fifteen  or  twenty 
minutes.  The  glycerin  can  be  handled  to  better  advantage  and  its 
measurement  more  accurately  made  by  warming  it  before  it  has  been 
poured  into  the  graduate  and  the  chemicals  have  been  added. 

"  Select  Calvert's  No.  1  crystallized  carbolic  acid  and  pour  a  sufficient 
quantity,  liquefied  by  warmth,  into  a  2-ounce  graduate  to  measure  1 
ounce,  and  add  2  drams  of  distilled  water.  To  this  add  enough  of 
the  glyceride  of  lead  and  borax  previously  made  to  make  the  combina- 
tion measure  exactly  2  ounces. 


HEMORRHOIDS— PILES  625 

!^   Acidi  carbol.  cryst 5j; 

Aqiite  destillati oij; 

Sod.  bibor.  et  pkimb.  glyc ovj. 

Misce  et  Sig.:  Solution  for  hgemorrhoids. 

'^  The  object  of  the  water  in  the  formula  is  to  lessen  the  sirup-like 
consistence  of  the  preparation.  Should  equal  parts  of  crystallized 
carbolic  acid  and  giyceride  of  lead  and  borax  be  combined,  the  solution 
will  be  found  rather  too  heavy  for  conyenience.  It  will  not  flow  through 
the  hsemorrhoidal  needle  as  freely  nor  take  hold  of  the  tissues,  when 
injected,  as  quickly  as  does  a  solution  containing  a  small  proportion  of 
water." 

Others  of  this  school  use  mixtures  of  carbolic  acid  with  olive-oil,  or 
other  substances,  and  vary  the  strength  from  25  to  75  per  cent. 

The  famous  BrinkerhofE  method  consists  in  injecting  hgemorrhoids 
with  the  following  mixture: 

1^  Ac.  carbolici   §j; 

01.  olivge    q\; 

Zinci  chlorid gr.  viij. 

From  two  to  eight  minims  are  injected  according  to  the  size  of  the 
pile. 

Carbolic  acid  is  the  principal  ingredient  in  them  all,  and  the  inten- 
tion is  to  destroy  the  hemorrhoid  by  causing  it  to  slough  off.  This 
necessarily  leaves  an  ulceration  of  the  rectum  which  may  give  more 
distress  than  the  piles,  especially  if  the  sphincter  is  not  dilated  and 
perfect  drainage  afforded.  To  avoid  any  misunderstanding,  the  author 
would  state  that  he  has  no  sympathy  with  this  method.  If  the  treat- 
ment of  liEemorrhoids  by  injection  is  to  be  followed  by  sloughing,  ulcera- 
tion, and  granulation,  and  the  patient  is  to  be  confined  to  his  bed  for 
a  week  or  more,  then  all  its  supposed  advantages  disappear.  An  ulcer 
produced  by  diffuse  cauterization  and  sloughing  is  never  as  healthy 
or  prompt  in  healing  as  a  clean  surgical  wound,  and  can  not  be  so 
accurately  limited  to  the  diseased  tissue.  The  pain  during  the  period 
of  sloughing  is  greater  than  that  following  surgical  operations,  and 
the  dangers  of  abscess  or  sepsis  by  absorption  from  the  necrotic  area 
are  incomparably  more.  The  patient  escapes  general  anaesthesia,  but 
at  the  expense  of  time,  pain,  uncertainty,  and  danger.  If,  therefore, 
the  hemorrhoid  is  to  be  removed,  let  it  be  done  by  scientific  surgical 
methods.  If,  however,  the  hgemorrhoids  can  be  eradicated  without  pain, 
sloughing,  ulceration,  or  confinement,  it  will  be  a  distinct  improve- 
ment over  operative  measures;  this  is  what  is  claimed  for  the  second 
method  of  injection,  and  in  properly  selected  cases  it  is  believed  that 
the  claim  can  be  substantiated.  The  principle  upon  which  this  method 
40 


626  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

is  based  consists  in  the  production  of  an  inflammatory  induration  of  the 
ha^morrhoidal  mass  through  which  the  circulation  is  retarded  or  partially 
cut  off,  hut  which  does  not  go  to  the  extent  of  cauterization  or  strangulation 
so  as  to  result  in  sloughing.  The  cases  to  which  it  is  applicable  are 
those  of  uncomplicated  internal  haemorrhoids  which  can  be  brought 
into  view  and  sterilized,  in  which  no  ulceration  and  no  external  haemor- 
rhoids exist,  and  in  which  the  sphincters  are  comparatively  relaxed. 

The  Operation. — The  patient  should  be  just  as  carefully  prepared 
for  injection  as  for  any  other  operation  for  hemorrhoids.  The 
sphincter  should  be  gradually  and  gently  dilated,  a  procedure  that  may 
require  two  or  three  days  if  it  is  spasmodic.  The  bowels  should  be 
carefully  emptied  the  night  before  the  injection  by  a  laxative,  and  a 
saline  enema  should  be  given  one  hour  previous  to  the  treatment.  If 
it  is  difficult  to  bring  the  haemorrhoids  into  view,  the  patient  should 
sit  upon  a  vessel  filled  with  hot  water  and  strain  for  a  few  moments 
in  order  to  bring  the  tumors  down;  when  this  is  accomplished  he  is  laid 
upon  the  side  to  which  the  haemorrhoids  to  be  injected  are  attached. 
While  he  pulls  upward  with  one  hand  upon  the  upper  buttock,  an  assist- 
ant pulls  downward  on  the  lower  one,  and  thus  the  tumors  are  steadied 
and  kept  outside  of  the  anus.  They  are  then  thoroughly  but  gently 
washed  with  soap  and  l-to-2,000  bichloride  solution,  after  which  they 
are  dried  and  the  injection  is  made.  The  needle  is  introduced  at  the 
juncture  of  the  tumor  with  the  normal  mucous  membrane  below,  and 
carried  well  across  its  base.  The  finger  is  then  introduced  into  the 
anus  to  ascertain  that  the  needle  has  not  penetrated  or  closely  ap- 
proached the  mucous  membrane  above.  Small  amounts  of  the  fluid  are 
then  slowly  injected,  partially  withdrawing  the  needle  and  reintrodu- 
cing it  in  different  directions  so  as  to  distribute  the  fluid  as  equably 
as  possible  over  all  the  base;  after  this  the  needle  is  carried  upward 
into  the  body  of  the  tumor  and  a  small  quantity  of  fluid  is  injected 
near  its  center.  The  needle  is  then  left  in  situ  for  one  or  two  minutes 
in  order  that  the  fluid  may  become  disseminated  and  not  flow  out 
through  the  point  of  puncture.  A  small  pledget  of  cotton  soaked  in 
alcohol  is  placed  around  the  needle  so  as  to  cover  the  puncture  when 
it  is  withdrawn  and  to  prevent  the  fluid  which  may  escape  from  irrita- 
ting the  surrounding  tissues.  The  tumor  is  kept  outside  of  the 
sphincter  for  two  or  three  minutes  in  order  that  the  squeezing  neces- 
sary to  reduce  it  will  not  force  the  fluid  into  other  portions  than  those 
into  which  it  was  injected;  it  is  then  reduced,  a  small  compress  of 
cotton  is  placed  upon  the  anus  and  held  there  flrmly  by  a  j-l^andage, 
the  patient  being  required  to  lie  still  for  ten  or  flfteen  minutes.  It  is 
best  to  keep  him  quiet  for  a  few  hours  after  the  first  injection,  because 
the  inflammatory  action  produced  in  one  patient  is  never  any  guide  as 


HEMORRHOIDS— PILES  627 

to  what  will  be  produced  by  the  same  injection  in  another;  after  this 
if  there  is  no  great  pain  or  swelling  he  may  go  about  his  usual  avoca- 
tions. On  the  day  following  the  injection  the  tumor  will  be  found 
to  consist  of  a  tense,  hard  mass,  not  particularly  painful  to  the  touch 
and  of  a  bright-red  color.  It  remains  in  this  condition  for  two  or 
three  days,  after  which  it  begins  to  shrivel,  and  eventually  there 
is  nothing  left  at  its  site  but  an  apparently  normal  mucous  mem- 
brane somewhat  more  closely  attached  to  the  deeper  tissues  than  is 
normal. 

The  Numler  of  Tumors  to  he  Injected. — ^Miere  there  are  several 
tumors  it  is  well  to  select  the  one  which  is  apparently  causing  the 
patient  the  most  inconvenience,  either  through  prolapse  er  bleeding, 
and  inject  this  one  first.  It  is  not  advisable  to  inject  more  than  one 
tumor  at  the  first  sitting.  After  this,  if  there  is  no  unusual  disturb- 
ance, one  may  with  safety  prepare  the  patient  and  inject  at  the  follow- 
ing sitting  two  or  three  of  the  remaining  tumors  in  the  same  manner. 
The  second  injection  should  not  be  made  sooner  than  five  days  after 
the  first. 

The  Eepetition  of  Injections. — In  the  majority  of  instances  one  never 
has  to  inject  the  same  tumor  more  than  once,  but  sometimes  through 
overcautiousness  and  the  injection  of  too  small  a  quantity  of  fluid, 
sufficient  inflammatory  reaction  to  obliterate  the  pile  is  not  produced 
and  then  the  injection  must  be  repeated. 

The  Solution. — After  having  tried  many,  substances,  the  following 
modification  of  Shuford's  solution  has  proved  the  most  satisfactory: 

^  Ac.  carbolici  (Calvert's) oij; 

Ac.  salicylici   oss.; 

Sodii  biborate  oj; 

Glyeerinse  (sterile) q.  s.  ad.  gj. 

M.    Sec.  Art. 

The  fluid  should  be  of  a  sirupy  consistence  and  perfectly  clear.  A 
mUky-white  appearance  is  due  to  imperfect  solution,  and  invalidates 
its  usefulness.  The  action  of  the  salicylic  acid  consists  in  softening 
and  destroying  the  epithelial  and  endothelial  cells,  thus  producing  an 
inflammation  of  the  venous  walls  which  eventually  causes  them  to  ad- 
here together  and  completely  obliterates  their  caliber.  The  biborate 
and  carbolic  acid  act  as  irritants  and  antiseptics,  causing  the  inflamma- 
tion in  the  perivascular  tissues. 

Amount  of  Fluid  to  he  Injected. — The  amount  of  fluid  to  be  injected 
in  any  individual  tumor  will  depend  upon  its  size.  It  is  difficult  to 
lay  down  any  absolute  rules  for  this;  the  largest  tumor  never  requires 
more  than  10  minims,  and  the  quantity  must  be  graduated  from  this 


Fig.  197. — Gant's  Syringe  for  injecting  Hjimorrhoids. 


628  THE  ANUS,  RECTUM,  AND  PELVIC   COLON 

amount  down  to  2  or  3,  the  average  injection  being  about  5  minims 
of  the  solution. 

The  Instrument. — No  special  instrument  is  necessary  to  make  these 
injections.  An  ordinary  hypodermic  syringe  with  a  metal  plunger  and 
a  No.  21  hypodermic  needle  are  all  that  are  required.  Fine  needles  do 
not  allow  the  fluid  to  flow  easily.     It  is  convenient  to  have  handle-bars 

upon  the  syr- 
inge in  order  to 
steady  it,  as  it 
sometimes  re- 
quires consider- 
able strength  to 
force  the  fluid 
through  the 
needle.     Special 

syringes  and  needles,  such  as  those  devised  by  Agnew  and  Gant,  are 
convenient,  no  doubt,  but  they  are  not  necessary.  The  curved  extension 
on  Gant's  syringe  (Fig.  197)  can  be  attached  to  any  ordinary  hypodermic 
syringe,  and  allows  the  operating  hand  to  drop  out  of  the  line  of  vision, 
and  is  therefore  useful. 

The  After-treatme7it. — After  a  hfemorrhoid  has  been  injected  by  this 
method  there  is  comparatively  little  pain,  and  no  opiates,  sedatives, 
or  local  applications  are  required.  A  suppository  of  opium,  belladonna, 
and  iodoform  may  be  introduced  for  the  flrst  two  nights  to  prevent 
the  bowels  from  moving,  but  it  is  not  necessary  for  the  relief  of  pain. 
The  bowels  are  confined  for  forty-eight  hours,  after  which  they  are 
moved  either  by  a  gentle  laxative  or  a  cold-water  enema.  This  is 
repeated  every  day,  and  the  patient  is  allowed  to  go  about  his  business 
after  the  first  twenty-four  hours.  Thus  practically  there  is  no  after- 
treatment.  The  inflammatory  condition  gradually  subsides,  and  the 
protrusion  and  bleeding  usually  cease  from  the  flrst  day. 

Accidents  and  Complications. — Prolapse  of  an  injected  htemorrhoid 
may  occur  within  the  flrst  twelve  or  fourteen  hours  after  the  opera- 
tion. The  patient  should  be  warned  against  straining  or  too  long 
standing  until  the  danger  of  this  has  passed.  If  by  any  accident, 
through  passing  gas  or  otherwise,  the  injected  tumor  should  slip  out- 
side of  the  sphincter,  it  should  be  replaced  at  once  by  gentle  pressure 
with  a  soft  sponge  or  wad  of  cotton;  if  the  patient  is  unable  to  do 
this  he  should  send  for  a  physician  and  have  it  done  at  once.  If  this 
is  not  done  strangulation  and  sloughing  may  occur. 

Sloughing. — Since  beginning  this  method  of  treatment  the  author 
has  had  sloughing  in  3  cases  only;  in  these  he  was  unable  to  account 
for  the  cause  unless  it  was  due  to  his  having  injected  the  fluid  too 


H^MOERHOIDS— PILES  629 

close  to  the  surface  of  the  tumor.  The  condition  in  each  of  these 
cases  was  simply  a  sloughing  out  of  the  central  portion  of  the  tumor, 
leaving  a  sort  of  fissure  between  the  hardened  masses  upon  each  side. 
In  1  of  them  the  tumor  was  low  down  and  occasioned  a  great  deal  of 
pain  and  annoyance;  in  the  other  2  the  tumors  being  high  up  gave  the 
patients  no  trouble  whatever  beyond  the  alarm  occasioned  by  seeing 
a  little  blood  and  pus  secreted  from  the  rectum.  All  3  cases,  how- 
ever, recovered  after  five  or  six  weeks,  and  the  tumors  entirely  dis- 
appeared. 

As  to  abscess,  sepsis,  haemorrhage,  thromboses,  and  affections  of  the 
liver,  which  are  said  to  follow  this  method  of  treatment,  the  author 
has  had  no  experience  with  any  one  of  them;  sepsis  or  abscess  is  hardly 
possible  if  it  is  properly  carried  out.  There  is  nothing  in  the  solution 
that  is  septic  or  capable  of  producing  pus;  if  the  needles  and  the  syringe 
are  properly  sterilized  before  they  are  used,  and  if  the  tumor  is  cleansed 
with  antiseptic  solutions  so  that  no  infecting  germs  can  be  carried  in 
from  its  surface  by  the  needle,  it  is  not  likely  that  an  abscess  or  an 
infection  of  any  kind  will  ever  be  produced  by  it.  Gant,  who  has 
employed  the  method  for  a  considerable  time  and  with  more  or  less 
success,  records  one  notable  failure  in  his  experience  in  which  an  abscess 
and  slough  were  produced  by  injecting  a  hgemorrhoidal  tumor.  He 
states,  however,  that  upon  careful  examination  he  found  in  the  abscess 
a  small  focus  in  which  there  rested  a  minute  mass  of  fgeeal  matter 
evidently  carried  in  upon  the  end  of  his  needle,  thus  accounting  for 
the  infection  of  the  tumor. 

Hgemorrhages  can  not  occur  when  the  mucous  membrane  is  not 
broken  through  ulceration  or  sloughing,  and  as  the  method  does  not 
produce  this,  they  will  never  be  seen  unless  some  other  complication 
appears. 

Recurrences. — The  strongest  point  in  Kelsey's  argument  (op.  cit., 
p.  183)  against  this  method  of  treatment  consists  in  the  statement 
that  the  operation  does  not  radically  cure.  He  says  that  relief  con- 
tinues for  about  three  or  four  years,  after  which  the  hsemorrhoids 
return  even  worse  than  before.  Granting  that  this  is  true,  the  fact 
remains  that  the  haemorrhoids  are  in  no  worse  condition  for  operation 
upon  their  recurrence,  and  the  large  majority  of  patients  would  much 
prefer  to  take  this  chance  with  respite  from  the  operating-table  for 
so  considerable  a  time.  The  author  has  had  cases  return  to  him  for 
treatment  after  he  had  injected  internal  haemorrhoids,  but  upon  careful 
examination  it  has  nearly  always  been  found  that  the  haemorrhoid  was 
at  a  different  part  of  the  anal  circumference  from  that  at  which  the 
original  injection  was  made.  In  a  very  few  cases  recurrences  in  situ 
have  taken  place,  and  in  only  2  in  which  the  injection  treatment  was 


630  THE  ANUS,   RECTUM,  AND   PELVIC   COLON 

used  has  it  ever  been  necessary  to  do  a  more  radical  operation.  All 
the  recurrences  observed  have  taken  place  in  six  to  twelve  months, 
and  many  patients  injected  six  to  nine  years  since  have  never  had  the 
slightest  return. 

When  the  piles  do  recur,  they  may  be  treated  again  after  the  same 
method  quite  as  successfully  as  at  first.  The  probability  of  such  results 
should  be  frankly  stated  to  the  patient  before  adopting  this  line  of 
treatment,  but  the  majority  will  prefer  periodic  treatment  of  this 
kind  rather  than  submit  to  radical  operations.  It  is  not  claimed 
that  this  method  is  superior  or  even  equal  to  the  accepted  surgical 
procedures,  but  it  is  maintained  that  the  accidents  and  complications 
which  follow  it  have  been  greatly  exaggerated  by  writers  upon  this 
subject,  and  that  most  satisfactory  results  can  frequently  be  obtained 
through  it  in  properly  selected  cases. 

In  all  the  strictly  operative  methods  certain  preliminary  procedures 
are  necessary,  such  as  preparation  of  the  patient,  anesthesia,  and  dila- 
tation of  the  sphincter. 

Preparation  of  the  Patient. — In  order  to  obtain  the  best  results, 
patients  should  be  as  carefully  prepared  for  hsemorrhoidal  operations 
as  for  laparotomy.  The  bowels  should  be  thoroughly  emptied  twenty- 
four  hours  before  the  time,  and  only  light  diet  allowed  during  that 
period.  Eochelle  salts,  or  a  full  glass  of  Eubinat,  Apenta,  or  Hunyadi 
water,  given  early  in  the  morning  and  repeated  if  necessary  in  three 
hours,  will  accora])lish  this  purpose.  The  evening  before  the  opera- 
tion a  bichloride  dressing  should  be  applied  to  the  anus  and  retained 
by  a  T-bandage.  If  excision  is  to  be  practised,  the  perinseum  and  anus 
should  be  shaved,  but  this  is  not  necessary  for  the  ligature  or  clamp- 
and-cautery  operations.  The  patient  should  have  a  quiet,  restful  night 
before  the  operation,  even  if  trional  or  chloralamine  has  to  be  given. 
Three  hours  before  the  operation  a  salt-and-soap  enema  should  be 
given;  when  this  passes  the  parts  should  be  washed  and  the  dressing 
reapplied.  After  the  patient  is  anaesthetized  and  in  position  on  the 
table  the  sphincters  should  be  dilated,  the  rectum  irrigated  with  a  1- 
to-3,000  bichloride  solution,  and  the  external  parts  surgically  cleaned. 
The  order  of  procedure  in  this  is  important,  for  if  the  external  parts 
are  prepared  before  the  sphincter  is  stretched  and  the  rectum  cleansed, 
faecal  matter  from  the. latter  may  come  down  and  soil  the  outer  field. 
The  bladder  should  always  be  emptied  before  beginning  any  operation 
on  the  rectum,  and  if  necessary  this  should  be  done  with  a  catheter 
before  cleaning  up  the  operative  field. 

While  such  preparation  is  advisable  in  all  cases,  it  is  sometimes 
almost  impossible,  and  those  who  have  done  clinical  work  know  that 
it  is  not  indispensable  in  the  clamp-and-cautery  operation,  for  the  hot 


HEMORRHOIDS  631 

iron  destroj^s  germs  and  seals  the  lymphatic  and  blood-vessels  against 
septic  absorption. 

The  Ancesthetic. — Hgemorrhoids  may  be  operated  on  under  local  or 
general  anaesthesia.  The  chief  pain  is  produced  by  stretching  the 
sphincter^  and  it  is  said  by  Eeclus  and  Bodine  that  this  can  be  done 
painlessly  by  the  hypodermic  injection  of  weak  solutions  of  cocaine  or 
eucaine,  but  such  has  not  been  my  experience.  Infiltrating  the  parts  with 
sterile  water  does  not  obviate  the  pain  of  stretching  and  therefore  some 
prefer  to  cut  the  muscle.  This  we  consider  unnecessary  mutilation. 
If  these  local  methods  of  angesthesia  are  selected  the  ligature  or  Earle 
operation  should  be  employed.  In  the  clamp  and  cautery  operation  the 
inhalation  of  the  ethyl  chloride  or  nitrous  oxide  gas  is  quite  satisfactory. 
In  using  them  the  patient  should  be  given  a  hypodermic  injection  of 
morphine  ten  minutes  before  the  operation,  and  should  be  placed  in  the 
lithotomy  position  before  beginning  the  anaesthetic.  In  difficult  or  long 
operations,  ether  or  chloroform  should  be  employed. 

If  "  spinal  angesthesia "  proves  to  be  without  danger,  it  will  be 
superior  to  either  chloroform  or  ether  in  operations  for  hgemorrhoids, 
because  the  nausea  disappears  before  the  operation  is  completed,  the 
oozing  is  much  less,  and  the  anaesthesia  ■  is  so  prolonged  and  fades  so 
gradually  that  the  patient  is  practically  over  his  initial  pains  before 
sensibility  returns.  The  bowels,  however,  must  be  thoroughly  emptied 
before  attempting  plastic  operations  under  it,  as  involuntary  movements 
are  very  likely  to  occur  and  soil  the  operative  field.  The  remote  effects 
of  puncture  and  injection  of  foreign  fluid  into  the  spinal  canal,  how- 
ever, remain  to  be  seen. 

Position  of  the  Patient. — The  position  in  which  one  operates  is 
largely  a  matter  of  habit  and  early  teaching.  Allingham  and  the 
majority  of  operators  prefer  the  lithotomy  position,  Mathews  ad- 
vises the  Sims's  position,  and  some  operators  prefer  having  the  patient 
swung  in  the  knee-chest  posture.  The  lithotomy  position  is  gen- 
erally the  most  convenient  except  in  cases  with  anchylosed  hips,  and 
in  these  it  is  necessary  to  select  that  which  gives  the  easiest  access  to 
the  parts. 

The  Ligature. — The  ligature  has  been  for  many  years  the  most 
popular  method  among  surgeons  for  the  treatment  of  hgemorrhoids. 
It  has  numbered  among  its  advocates  the  most  noted  and  scientific 
men  in  the  medical  profession.  It  is  perhaps  to  Allingham  more  than 
to  any  other  that  this  operation  owes  its  popularity.  It  is  applicable 
to  almost  every  variety,  and  whatever  else  may  be  said  against  it,  no 
one  can  deny  its  effectiveness  in  the  cure  of  hgemorrhoids.  In  this 
country  Mathews  has  been  the  most  brilliant  and  consistent  advocate 
of  this  operation.     There  are  several  methods   of  applying  it.     The 


632 


THE  ANUS,  RECTUM,  AND  PEL"VaC  COLON 


three  which  will  be  described  are  those  of  Mathews,  Allingham,  and 
Rickets. 

Mathews's  Method. — The  patient  is  placed  in  Sinis's  position,  the 
sphincters  dilated,  and  forceps  or  small  retractors  are  used  to  bring 

the  haemorrhoids  into  view. 
Small  tumors  are  caught 
and  tied  off  with  fine 
thread,  either  linen  or  silk. 
Where  there  are  no  skin- 
tabs  or  hypertrophied  folds 
around  the  anus,  no  cutting 
whatever  is  done.  "  The 
large  tumors  are  caught 
well  at  their  base,  drawn 
stoutly  down  by  the  for- 
ceps, held  there  by  an  as- 
sistant, and  a  curved  needle 
threaded  with  stout  silk  is 
passed  immediately  through 
the  base.  The  needle  is 
now  cut  away  and  the  liga- 
tures tied  stoutly,  first  on 
one  side  of  the  tumor,  then 
on  the  other  (Fig.  198). 
Having  the  tumor  tightly 
tied  on  each  side,  the  pile  is  now  cut  off  with  a  pair  of  straight  scissors." 
The  amount  of  the  tumor  to  be  cut  away  is  a  matter  of  individual 
judgment,  although  Mathews  indulges  in  a  somewhat  extensive  argu- 
ment with  regard  to  the  danger  of  cutting  off  too  much  or  too 
little.  Only  so  much  of  the  mass  should  be  left  as  will  thoroughly 
hold  the  ligature.  After  the  tumors  are  removed,  he  places  a  piece 
of  iodoform  or  bichloride  gauze  against  the  stumps  and  pushes  them 
back  into  the  rectum.  A  large  anal  compress  is  placed  in  position 
and  held  by  a  T-bandage.  "  The  patient  is  then  given  a  hypodermic 
injection  of  ^  of  a  grain  of  morphine  and  j^  of  a  grain  of  sulphate 
of  atropine  before  he  is  taken  to  his  room.  This  is  repeated  in  one 
or  two  hours  if  necessary."  He  also  uses  sulphonal  in  15-  or  20-grain 
doses,  to  control  the  spasm  of  the  sphincter.  If  the  hemorrhoids  are 
complicated  by  external  connective-tissue  growths,  he  makes  an  incision 
in  the  skin  around  these  growths,  transfixes  them  along  with  the  in- 
ternal tumor,  and  ties  one  ligature  in  the  groove  produced  by  this 
incision  and  another  on  the  mucous  membrane.  He  then  cuts  off  the 
summit  of  the  tumors,  thus  removing  them  all  in  one  mass.     With 


Fig.  198. — Transfixion  anh  ],h,ati  i:k 

Hj:iIOKRHOID. 


HEMORRHOIDS— PILES 


633 


regard  to  the  amount  of  external  tissue  taken  off  with  external  haemor- 
rhoids, he  states  that  the  danger  is  always  in  taking  ofE  too  little  rather 
than  too  much;  that  one  of  the  most  annoying  complications  of  this 
operation  consists  in  an  inflammation  of  the  superfluous  flaps  of  skin 
at  the  margin  of  the  anus,  and  that  if  a  good  sweeping  cut  is  made 
entirely  around  the  skin-tab  to  be  removed,  the  patient  will  be  much 
more  comfortable  afterward  and  there  will  be  very  little  danger  of 
anal  stricture. 

AUingham's  Metliocl—T^he  operation  generally  known  as  Ailing- 
ham's  was  devised  by  Mr.  Salmon  more  than  fifty  years  ago,  and  has 
been  almost  invariably  practised  at  St.  Mark's  Hospital,  London,  since 
that  time.     The  method,  as  described  by  him,  is  as  follows: 

"  The  patient,  having  been  previously  prepared  by  purgatives,  is 
placed  on  the  right  side  on  a  hard  couch  in  a  good  light,  and  is  com- 
pletely anesthetized,  and  then  the  sphincter  muscles  are  gently  but 
completely  dilated.  This  completed,  the  rectum  for  3  inches  is  within 
easy  reach,  and  no  contraction  of  the  sphincters  takes  place,  so  that 
all  is  clear  like  a  map  before  one.  The  hsemorrhoids,  one  by  one,  are 
to  be  taken  by  the  surgeon  with  a  volsella  or  pronged  hook-fork  and 
drawn  down;  he  then,  with 
a  pair  of  sharp  scissors,  I 
separates  the  pile  from  its 
connection  with  the  muscu- 
lar and  submucous  tissues 
upon  which  it  rests;  the 
cut  is  to  be  made  in  the 
sulcus  or  white  mark  which 
is  seen  where  the  skin  meets 
the  mucous  membrane,  and 
this  incision  is  to  be  car- 
ried up  the  bowel,  and  par- 
allel to  it,  to  such  a  dis- 
tance that  the  pile  is  left 
connected  by  an  isthmus 
of  vessels  and  mucous  mem- 
brane only. 

"  There  is  no  danger  in 
making  this  incision,  be- 
cause all  the  larger  vessels 
come  from  above,  running 
parallel  with  the  bowel  just 

heneatJi  the  mucous  memhrane,  and  thus  enter  the  upper  part  of  the  pile. 
A  well-waxed,  strong,  thin,  plaited  silk  ligature  (Turner's  No.  6)  is  now 


Fig.  199.- 


-Ligation  of  H^moebhoid  afteb 
Allingham's  Method. 


634  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

to  be  placed  at  the  bottom  of  the  deep  groove  which  has  been  made, 
and  the  assistant  then  drawing  the  pile  well  out,  the  ligature  is  tied 
high  up  at  the  neck  of  the  tumor  as  tightly  as  possible  (Fig.  199). 
One  must  be  very  careful  to  tie  the  ligature,  and  equally  careful  to  tie 
the  second  knot,  so  that  no  slipping  or  giving  way  can  take  place. 
We  always  tie  a  third  knot;  the  secret  of  the  well-being  of  the  patient 
depends  greatly  upon  this  tying — a  part  of  the  operation  by  no  means 
easy  (as  all  practical  men  know)  to  effect.  If  this  be  done,  all  the 
large  vessels  in  the  pile  must  be  included.  The  arteries  in  the  cellular 
tissue  around  and  outside  the  bowel  are  few  and  small,  as  they  do  not 
assist  in  the  formation  of  the  pile,  being  outside  it.  These  vessels 
rarely  recjuire  ligaturing.  The  silk  should  be  so  strong  that  it  can 
not  be  broken  by  fair  pulling.  If  the  pile  be  very  large,  a  small  portion 
may  now  be  cut  off,  taking  care  to  leave  sufficient  stump  beyond  the 
ligature  to  guard  against  its  slipping." 

After  the  piles  have  been  tied,  if  they  are  small  ones  he  does  not 
cut  them  off,  but  leaves  them  to  be  cut  through  by  the  ligature.  Any 
skin-tabs  or  superfluous  muco-cutaneous  membrane  around  the  margin 
of  the  anus  are  cut  off  with  scissors,  the  bleeding  being  checked  by 
compression.  A  point  which  is  well  brought  out  by  Allingham  is  the 
necessity  of  making  the  pedicle  of  the  ha-morrhoidal  tumor  as  small 
as  possible  without  dividing  the  chief  arterial  supply.  If  it  is  large 
and  broad,  and  there  are  several  hfemorrhoids  about  the  rectum,  the 
ligatures  will  draw  the  mucous  membrane  together  and  produce  con- 
siderable contraction  of  the  caliber.  In  this  way  marked  stricture  may 
be  produced.  By  making  a  narrow  pedicle  one  leaves  little  strips  of 
mucous  membrane  around  the  rectum  which  conduce  to  rapid  healing 
of  the  parts. 

Operators  in  this  country  are  about  equally  divided  in  their  prefer- 
ences for  the  Mathews  and  Allingham  operations.  In  the  latter  the 
amount  of  tissue  to  be  cut  through  by  the  ligature  is  less  and  the 
granulating  surface  smaller,  but  there  is  more  danger  that  the  liga- 
ture will  slip  off  the  stump  and  cause  secondary  haemorrhage  than  in 
the  transfixion  method  of  Mathews.  But  hEemorrhage,  either  primary 
or  secondary,  from  haemorrhoidal  operations  seems  to  be  somewhat  of 
a  bugaboo  to  frighten  young  operators  and  make  them  careful.  In 
an  experience  of  twenty  years  the  author  has  never  seen  any  serious 
haemorrhage  follow  an  operation  for  hemorrhoids  by  injection,  liga- 
ture, clamp  and  cautery,  or  dissection,  save  in  1  case,  which  will  be 
detailed  later. 

Whatever  else  may  be  said  against  the  ligature  operation,  two  things 
stand  out  in  bold  relief:  it  is  slightly  if  at  all  dangerous  to  life,  and  it 
absolutely  cures  the  disease.     Accidents  and  deaths  have  followed  this 


HEMORRHOIDS— PILES  635 

operation,  as  they  have  almost  every  other  surgical  procedure.  They 
are  so  few,  however,  that  one  need  hardly  consider  them  when  the 
conditions  justify  the  removal  of  the  hemorrhoids.  Copeland,  Curling, 
Sir  Benjamin  Brodie,  Agnew,  Van  Buren,  Ashhurst,  Gross,  Sands, 
Cooper,  Goodsall,  and  hundreds  of  other  leading  surgeons  throughout 
this  country  and  Europe  have  expressed  their  preference  for  this  opera- 
tion over  all  others,  and  with  few  exceptions  have  seen  no  fatal  results. 
Allingham  has  recorded  five  deaths  in  over  four  thousand  operations; 
Curling  reported  one  death;  Agnew  saw  three  deaths  all  due  to  tetanus; 
and  Mathews,  up  to  the  time  he  com^^leted  his  thousandth  case,  had 
never  had  one  from  this  operation  in  his  own  practice. 

After-treatment. — Allingham  attributes  all  the  unfortunate  results 
which  follow  this  method  to  the  after-treatment.  He  confines  the 
bowels  for  four  or  five  days,  and  uses  opium  freely  for  this  purpose 
and  for  the  relief  of  pain.  On  the  day  following  the  operation  the 
outside  dressing  is  removed,  the  parts  are  dusted  with  iodoform  or 
some  other  powder,  and  after  this  only  small  pledgets  of  dry  gauze 
will  be  necessary.  To  some  patients  a  dressing  moistened  in  some  form 
of  antiseptic  solution  is  more  grateful. 

The  bowels  are  moved,  according  to  the  necessity  of  the  case,  after 
four  or  five  days.  "Whatever  laxative  is  selected  should  be  given  in 
suf&cient  dose  to  comj^el  the  movement  of  the  bowels  even  against  the 
patient's  resistance,  for  at  this  time  the  sphincter  will  have  regaiiied 
its  tonicity,  and  the  fear  of  pain  will  cause  the  patient  to  hold  the 
movement  back  as  long  as  possible.  Allien  the  inclination  for  a  move- 
ment begins  to  be  felt,  an  injection  of  warm  sweet-oil  into  the  rectum 
will  facilitate  it,  and  prevent  any  friction  by  the  fsecal  mass  upon  the 
stumps  and  ligatures.  In  the  majority  of  cases  the  patient  may  sit 
upon  the  commode  for  this  purpose;  it  makes  the  movement  easier  and 
causes  less  straining  than  when  the  bedpan  is  used.  As  Allingham 
says,  there  are  cases  so  ansemic  and  debilitated  that  the  recumbent 
posture  is  desirable,  and  in  these  the  use  of  the  bedpan  for  several 
days  will  be  necessary.  After  the  bowels  have  once  moved,  8  ounces 
of  boric-acid  solution  should  be  injected  into  the  rectum,  and  expelled 
again  in  order  to  wash  away  any  faecal  material  which  may  have  adhered 
to  the  raw  surfaces.  If  there  is  any  difficulty  in  obtaining  a  move- 
ment of  the  bowels,  the  finger  should  be  introduced  at  once  to  ascer- 
tain if  impaction  has  taken  place,  and  if  so  it  should  be  broken  up. 
Allingham  advises  the  introduction  of  the  finger  into  the  bowel  every 
day  after  the  first  week  in  order  to  avoid  any  contraction;  he  confines 
the  patient  to  bed  for  one  week  or  more,  and  does  not  allow  him  to 
walk  about  until  the  wounds  are  healed. 

After  the  bowels  have  moved  for  the  first  time,  gentle  traction 


636 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


should  be  made  upon  the  ligatures  daily  in  order  to  withdraw  them 
when  they  have  cut  their  way  through.  This  should  be  very  care- 
fully done  lest  too  much  dragging  should  tear  off  a  pedicle  and  thus 
bring  about  secondary  haemorrhage. 

The  time  required  for  complete  healing  by  these  two  methods  is 
from  twenty-five  to  forty  days.  The  period  of  confinement  to  bed  is 
from  five  days  to  three  weeks,  according  to  the  temerity  of  the 
operator. 

Submucous  Ligature.— MeTrill  Eicketts,  of  Cincinnati,  has  recom- 
mended the  submucous  ligation  of  haemorrhoids.  He  claims  for  it  the 
following  advantages:  Impossibility  of  secondary  hemorrhage;  no  tissue 

is  destroyed  or  sacrificed; 
the  time  of  confinement  is 
very  short;  there  is  no  pro- 
tracted ulceration,  and  in 
his  experience  up  to  the 
time  of  the  report,  there 
had  been  no  infection  of 
any  kind;  the  pain  is  less 
than  by  other  methods  of 
ligation;  there  is  absolute- 
ly no  contraction  in  the 
caliber  of  the  gut. 

His  method  is  as  fol- 
lows: The  sphincters  are 
dilated  and  the  parts  pre- 
pared, as  has  been  already 
described.  A  needle  curved 
to  rather  more  than  a  semicircle,  and  threaded  with  moderate-sized  kan- 
garoo tendon,  is  passed  submucously  around  the  base  of  each  prominent 
haemorrhoid  (Fig.  200).  After  the  ligatures  have  all  been  passed,  they 
are  then  tied  so  that  the  knot  slips  through  the  aperture  made  by  the 
needle  and  buries  itself  in  the  submucous  tissue,  the  ends  being  cut  off 
very  short.  After  this  the  haemorrhoids  become  very  much  distended, 
and  it  is  sometimes  necessary  to  puncture  the  larger  ones  and  allow  the 
blood  to  escape  in  order  to  prevent  sloughing.  The  tumors  are  then 
replaced  within  the  sphincter,  and  a  firm  compress  placed  upon  the 
anus  to  prevent  their  prolapsing. 

Eicketts  states  that  "  after  a  few  weeks "  atrophy  takes  place  to 
such  a  degree  as  to  completely  destroy  all  the  objectionable  "  varices  " 
which  formerly  existed. 

The  method  sounds  reasonable,  and  is  no  doubt  effectual,  but  the 
dangers  of  infection  and  subsequent  abscess  must  not  be  ignored.    Some 


Fig.  200. — SrBccTA>T:ors  Ligature  of  a  Hj;iiobrhoid. 


HEMORRHOIDS— PILES  637 

little  experience  with  tlie  buried  ligature  in  the  treatment  of  rectal 
prolapse  has  convinced  the  writer  that  this  danger  is  less  than  is  usually 
supposed,  and  Eicketts's  experience  corroborates  this  view.  If  the 
ligatures  overlap  or  loop  into  each  other  the  method  will  result  in  a 
certain  amount  of  contraction  in  the  caliber  of  the  rectum. 

Clamp  and  Cautery. — This  operation  for  haemorrhoids  was  first 
suggested  by  Cussack  about  1846.  His  method  consisted  in  clamping  the 
h^emorrhoid  with  a  strong  forceps,  cutting  ofE  the  protruding  portion, 
and  cauterizing  the  stump  with  nitric  acid.  Mr.  Henry  Lee  adopted 
the  method  in  England,  and  it  was  through  his  influence  that  Henry 
Smith  was  led  to  put  it  into  practice  in  1861.  He  did  not  use  nitric 
acid,  but  cauterized  the  ends  of  the  stump  with  the  actual  cautery. 
He  emphasizes  the  importance  of  having  the  blades  of  the  clamps 
mortised  on  one  side  and  elevated  on  the  other,  with  serrated  edges, 
and  even  in  his  early  operations  called  attention  to  the  fact  that  the 
catching  of  integument  in  the  clamp  caused  more  pain  than  all  the 
rest  of  the  operation.  The  principles  upon  which  the  operation  is 
based  consist  in  the  double  protection  against  haemorrhage  through 
crushing  and  cauterization,  the  destruction  by  the  actual  cautery  of 
aU  septic  germs  which  may  be  distributed  over  the  parts  at  the  time 
of  the  operation,  and  in  sealing  up  capillaries  and  13'niphatics  to 
prevent  septic  absorption.  The  operation  is  completed  at  one  sit- 
ting; there  are  no  ligatures  to  cut  through  by  slow  and  tedious  proc- 
ess; there  is  no  protracted  irritation  about  the  nerves,  no  sutures 
to  be  removed,  and,  according  to  the  pathology  of  Smith's  day,  the 
operation  was  thus  free  from  the  dangers  of  tetanus.  After  a  pro- 
longed experience  with  this  method,  the  author  agrees  with  the  state- 
ment of  Smith  that  there  is  no  operation  which  compares  with  it  for 
universal  application,  ease  of  performance,  certainty  of  results,  and 
freedom  from  after-complications.  One  objection  to  the  operation  is 
that  it  requires  a  somewhat  elaborate  paraphernalia.  The  clamp,  the 
proper  kind  of  forceps,  the  Paquelin  or  iron  cautery  with  a  heating 
apparatus,  are  indispensable  to  its  performance.  The  objections  offered 
by  Allingham,  Mathews,  and  some  other  advocates  of  the  ligature, 
that  this  operation  is  painful,  subject  to  secondary  haemorrhages,  and 
often  produces  stricture,  are  without  foundation  in  the  experience  of 
those  who  have  used  it  most.  If  any  operator  should  take  up  an  ex- 
ternal or  mixed  pile  and  apply  a  ligature  around  it  without  cutting  a 
groove  in  the  skin  or  dissecting  up  a  pedicle,  these  two  eminent  authors 
would  stamp  him  at  once  as  a  tyro  in  surgery,  and  would  not  hesitate 
to  disclaim  such  operations  as  representative  of  their  own.  Yet  the 
description  and  illustrations  of  Smith's  operation  in  the  books  of  the 
surgeons  Just  mentioned  are  equally  as  far  from  the  correct  technique 


638 


THE  AXCS.   RECTUM.   AXD   PELVIC   COLON 


of  the  elamp-and-cautery  operation.  Its  freedom  from  pain,  the  dan- 
gers of  secondary  haemorrhage,  protracted  ulceration,  prolonged  dysuria, 
and  the  short  con- 
finement which  it 
necessitates,  render 
it  one  of  the  sim- 
plest and  surest  of 
surgical  procedures. 

The    Forceps.  —     Rv  Jl         Fig.  201. — Ttttle's  Hj:morrhoidal  Forceps. 

If  the  tumor  be 
taken  off  in  a  line  parallel  with  the  long  axis  of  the  gut,  the  cicatrix 
will  tend  to  hold  the  mucous  membrane  in  position,  overcome  any 
inclination  to  prolapse,  and  if  it  contracts  it  can  only  shorten  the  rectum 
and  not  narrow  its  caliber.  Appreciating  this  fact,  the  author  devised, 
some  years  ago,  the  forceps  illustrated  in  Fig.  201.  As  will  be  seen,  the 
instrument  possesses  a  linear  bite  of  about  f  of  an  inch  in  length,  in 

each  jaw  of  which  there  are 
four  sharp  teeth.  The  jaws  of 
the  forceps  are  parallel  with 
the  blades,  and  the  handles 
are  provided  with  a  lock  catch, 
so  that  when  the  haemorrhoid 
is  once  grasped  it  will  neither 
tear  out  nor  be  let  loose.  By 
introducing  the  instrument 
parallel  with  the  long  axis  of 
the  gut,  it  is  impossible  to 
catch  the  tumor  in  any  other 
line  (Fig.  202),  and  by  apply- 
ing the  clamp  under  the  for- 
ceps (Fig.  203),  it  will  always 
grasp  the  tumor  in  this  same 
line.  The  resulting  cicatrix 
will  necessarily  run  up  and 
down  the  rectal  cavity  and 
not  around  it.  This  instru- 
ment facilitates  the  operation 
greatly  as  well  as  accomplishing  the  given  end,  and  although  not 
indispensable,  it  is  a  most  useful  adjuvant  in  the  clamp-and-cautery 
operation. 

The  Clamp. — Almost  every  operator  who  has  relied  largely  upon 
this  operation  for  haemorrhoids  has  at  some  time  or  other  devised  a 
clamp  after  his  own  views.     The  original  clamp  of  Lee  consisted  in  a 


l-'i(j.  2U2. 


-Pile  seized  with  nj;Mor.RUOiDAL 
Forceps. 


HEMORRHOIDS— PILES 


639 


sort  of  curved  fenestrated  forceps  by  which  the  tumor  was  clamped 
and  crowded  into  a  central  pedicle  or  mass;  that  devised  by  Smith  has 
flat  blades,  on  one  side  of  which  are  ivory  plates  intended  to  prevent 
the  transmission  of  heat  to  the  tissues  beneath  during  the  cauterization; 
the  blades  are  also  very  wide  in  order  to  protect  the  surrounding  parts 
from  being  touched  by  the  cautery.  These  ideas  are  ingenious,  but  the 
ivory  plates  are  unnecessary,  and  the  broad  blades  are  inconvenient, 
especially  in  stout  people.  Gant's  clamp  (Fig.  304)  is  a  modification 
of  Smith's,  and  has  the 
merit  that  the  blades 
open  and  close  absolutely 
parallel. 

The  author  uses  the 
original  Kelsey  modifica- 
tion of  Smith's  clamp 
(Fig.  205).  It  differs 
from  the  latter  in  hav- 
ing longer  and  more  con- 
venient handles,  which 
afford  an  opportunity  for 
a  stronger  grasp:  the 
blades  are  narrower,  have 
no  ivory  plates  beneath 
them,  and  are  provided 
with  a  tongue  and 
groove,  all  three  edges 
being  serrated  in  order 
to  prevent  the  tumor's 
slipping  as  it  is  grasped 
by  the  clamp.  The  in- 
strument is  a  powerful 
one,      and      affords      the 

means  of  completely  crushing  a  tumor,  if  necessary;  the  older  patterns 
had  rubber  handles,  but  these  have  been  supplanted  by  metallic  ones 
which  can  be  sterilized  without  injur}^  Ware  has  improved  this  clamp 
by  substituting  a  ratchet  catch  for  the  screw. 

The  Cautery. — It  consists  in  a  reservoir  containing  benzine,  which 
is  connected  with  a  double  hand-bulb  upon  one  side  and  an  ingenious 
hollow  platinum  knife  or  bulb  upon  the  other.  The  platinum  point 
is  heated  to  a  dull-red  heat  in  the  alcohol  flame,  and  then  the  benzine 
vapor  is  pumped  into  it,  causing  combustion  and  the  maintenance  of 
heat  to  any  degree  required. 

There  are  a  number  of  modifications  of  this  instrument  in  the  shops. 


Fig.  203. — Method  of  applying  the  Claiip  aitee  the 
h^moeehoid  is  dragged  down. 


640 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


Fig.  204. — Gant's  Hemor- 
rhoidal Clamp. 


but  in  most  of  them  the  platinum  knife  is  made  so  light  that  it  will 
not  retain  the  heat  when  applied  to  a  wet  surface,  and  one  has  con- 
tinually to  wait  and  fire  it  up  again.  In  some 
of  them  the  blade  is  heated  by  the  benzene  being 
vaporized  and  burned  upon  the  outside  of  the 
knife  so  that  the  alcohol-lamp  is  unnecessary 
(Fig.  206).  Gasoline  may  be  used  instead  of 
benzene  in  these  instruments. 

The  fact  that  these  instruments  so  frequent- 
ly get  out  of  order  renders  a  few  words  upon 
their  management  not  inappropriate.  The  in- 
strument is  based  upon  the  principle  that  highly 
combustible  gases  ignite  at  a  low  temperature, 
and,  continuing  to  burn,  increase  the  heat  in 
the  bulb  or  knife.  There  is  one  tube  leading 
into  the  bulb  which  carries  the  vapor  and  a 
second  one  for  the  escape  of  any  superfluous 
amount.  Now,  if  the  vapor  is  pumped  into  the 
bulb  before  the  latter  is  heated  to  a  tempera- 
ture sufficient  to  ignite  it,  carbon  will  be  formed 
which  obstructs  either  the  entrance  or  exit  to 
the  blade,  and  thus  prevents  the  proper  action 
of  the  instrument.  A  mistake  is  frequently  made  in  pumping  the 
vapor  through  the  instrument  after  it  has  cooled  off.  As  surely  as 
this  is  done^  the  instrument  will  not  work  the  next  time  it  is  tried. 
If  one  is  careful  alwa^'s  to  avoid  this  and  have  the  platinum  tip 
well  heated  before  compressing  the  bulb,  the  instrument  will  rarely 
be  out  of  order.  When  the  accident  which  thus  disables  the  appa- 
ratus happens  to  occur,  it  is  well  to  know  that  by  placing  the  in- 
strument in  the  flame  of  an  alcohol-lamp  or  a  Bunsen  burner  and 
heating  it  to  a 
white  heat,  at  the 
same  time  pump- 
ing air  through  it, 
the  carbon  will  be 
consumed  and  the 
instrument  will  be 
restored  to  its 
usefulness.  An- 
other point  to  be 

remembered  is,  that  in  that  variety  of  reservoir  which  consists  in  a 
metal  tank  lined  with  sponge,  one  should  always  be  careful  to  put 
no   more  benzene  in   than  the   sponge  will  absorb.     If   too   much  is 


Fig.  205. — H.emorrhoidal  Clamp. 


HEMORRHOIDS— PILES 


641 


placed  in  the  tank,  it  will  be  carried  as  a  liquid  into  the  instru- 
ment and  thus  obstruct  it.  Before  etherizing  the  patient  to  operate 
by  this  method,  one  should  always  carefully  examine  his  cautery  and 
see  that  it  is  in  working  order,  else  he  may  be  caught  in  the  predica- 
ment where  the  clamp  has  been  applied,  the  hsemorrhoid  excised,  and 
the  cautery  will  not  burn.  If  the  precautions  mentioned  above  are 
observed,  the  Paquelin  cautery  will  be  found  a  most  useful  and  reliable 
instrument,  not  only  for  this  operation,  but  for  many  other  conditions 
which  one  meets  in  a  surgical  experience.  It  should  always  be  used 
at  a  dull-red  heat  for  controlling  hemorrhage,  as  the  white  heat  cuts 
the  vessels  and  does  not  shrivel  and  contract  them  as  the  red. 

The  use  of  the  galvano-cautery  in  operating  for  piles  is  frequently 
suggested  (Cutler,  Times  and  Eegister,  jSTovember  14,  1891).    The  heat 


Fifi.  206. — Modified  Paquelin  Cautery  (Kennedy's). 

is  too  intense  and  too  easily  reduced  to  make  it  satisfactory  even  when 
the  street  current  is  used,  and  in  operations  at  the  patients'  houses  it 
is  altogether  impracticable. 

Tlie  Operation  Itself. — The  patient  having  been  anaesthetized,  is  held 
in  the  lithotomy  position  by  a  Clover's  crutch  (Fig.  130)  or  the  up- 
rights of  a  modern  operating-table.  The  foot  of  the  table  should  be 
somewhat  higher  than  the  head,  and  on  a  level  with  the  shoulders  of  the 
operator  who  sits  upon  a  stool.  The  patient  being  in  position,  the  skin- 
tabs  should  be  clipped  off  flush  with  the  skin  before  stretching  the 
sphincter,  otherwise  they  swell  up  to  such  an  extent  that  it  is  difficult 
to  determine  how  much  ought  to  be  removed.  After  this  the  sphincter 
should  be  dilated  and  the  parts  prepared  as  already  described. 

After  the  sphincter  is  dilated  and  the  piles  brought  into  view,  one 
should  carefully  note  the  position  of  the  prominent  hasmorrhoidal  tu- 
mors. Generally  they  will  be  found  to  consist  of  three  large  ones: 
41 


642 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


one  upon  each  side  of  the  posterior  commissure,  and  one  just  to  the 
right  of  the  anterior  commissure,  with  occasionally  a  small  hsemor- 
rhoid  to  the  left  of  the  latter,  and  one  directly  opposite  the  posterior 
commissure.  The  important  ones  are  the  two  lateral  and  one  anterior 
tumors.  If  these  three  are  removed  the  others  will  generally  dis- 
appear spontaneously,  especially  if  they  are  very  small.  They  should 
also  be  removed  if  of  considerable  size.  Having  located  the  tumors,  they 
may  be  allowed  to  recede  if  they  do  so  spontaneously.  The  hsemor- 
rhoidal  forceps  (Fig.  201)  is  then  introduced  closed  directly  over  one  of 
the  lateral  tumors,  and  as  it  is  pressed  outward  in  the  direction  of  the 
latter,  it  should  be  gently  opened  to  the  extent  of  about  1  inch,  and 
closed  again.  By  this  procedure  the  tumor  rises  into  the  grasp  of  the 
forceps,  it  is  caught  directly  in  the  line  of  the  axis  of  the  gut,  and  it  can 
be  easily  pulled  down  into  view.  Some  little  knack  and  practice  are 
necessary  to  accomplish  this  deftly,  and  the  beginner  in  this  operation 

will  do  well  to  intro- 
duce a  Sims's  duck-bill 


speculum  upon  the  op- 
posite side,  or  drag  the 
tumor  down  and  catch 
it  by  sight  instead  of 
by  touch,  as  above  de- 
scribed. When  the  tu- 
mor has  been  grasped 
and  dragged  down,  if 
it  is  covered  in  its 
lower  portion  by  muco- 
cutaneous or  cutaneous 
tissue,  a  groove  (Fig. 
207)  should  be  cut  into 
these  sufficiently  deep 
to  prevent  their  being 
grasped  by  the  clamp. 
The  application  of  the 
clamp  and  cautery  to 
the  inuco  -  cutaneous 
tissues  or  the  skin  is 
the    cause    of    almost 


Fig.  207.— Gi:l 


-L    .11     i-M'..    .Mi;CU-(.LTA.\LuLs    Tl;.SL-E    INTO 

WHICH  THE  Clamp  fits. 


all  the  pain  associated 
with  this  operation,  and  if  this  little  precaution  is  strictly  adhered  to 
the  suffering  following  this  operation  will  be  comparatively  slight.  The 
clamp  is  now  slipped  over  the  forceps  (Fig.  203),  the  heel  being  upward 
in  reference  to  the  rectum,  for  the  reason  that  if  by  any  accident  part 


H:^MOERHOIDS— PILES 


643 


of  the  tumor  should  slip  out  of  its  grasp,  it  ^vould  always  be  the  lower 
portion,  which  is  the  least  tightly  held.  This  will  be  within  view,  and 
any  bleeding  from  it  can  be  easily  controlled.  The  tumor  having  been 
grasped  by  the  clamp,  with  the  blades  of  the  latter  fitting  into  the 
sulcus  cut  in  the  muco- 
cutaneous covering,  the 
screw  upon  the  clamp 
should  always  be  tight- 
ened in  order  to  pre- 
vent any  possible  re- 
laxation of  the  grasp 
until  the  cautery  has 
been  applied.  The  for- 
ceps should  then  be  re- 
moved, and  the  smn- 
mit  of  the  tumor  cut 
off  to  about  -J  of  an 
inch  of  the  clamp  (Fig. 
208),  thus  leaving  a 
stump  sufficient  to  be 
thoroughl}'  charred 
without  destroying 
that  part  of  the  tu- 
mor which  is  crushed 
b}^  the  clamp.  This  is 
an  important  jjart  of 
the  technique,   as   the 

crushed  portion  of  the  stump  forms  the  original  barrier  to  htemor- 
rhage  and  should  never  be  destroyed  by  burning  down  between  the 
blades  with  the  edge  of  a  Paquelin  knife,  as  is  sometimes  done. 
The  tumor  having  been  removed,  the  stump  should  then  be  cauter- 
ized with  a  Paquelin  or  iron  cautery  heated  to  a  dull-red  heat;  it  is 
not  necessary  to  burn  the  tissue  all  awa}^,  but  simply  to  char  it  thor- 
oughly until  it  presents  a  smooth  black  surface;  the  grasp  of  the  clamp 
should  then  be  slowly  relaxed  in  order  to  observe  if  there  is  any  point 
at  which  there  is  bleeding  from  the  stump.  In  case  there  is,  the  clamp 
should  be  retightened  and  the  cautery  reapplied.  If  there  is  no  bleed- 
ing, the  clamp  may  be  removed  and  the  stump  will  spontaneously  recede. 
The  second  lateral  tumor  and  then  the  anterior  one  should  be  treated 
in  like  manner,  and  if  the  operator  deems  it  advisable  he  may  also  re- 
move the  two  smaller  tumors  which  sometimes  exist  upon  the  left  an- 
terior and  central  posterior  quadrants. 

The  tumors  having  been  removed,  there  ar^i  two  methods  of  treating 


Fig.  '20S. — Sxuiip  oi"  Excised  H.eiiorrhoid  held  bt  Clahp. 


644  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

the  wounds:  one  is  the  application  of  a  soft  tliiffy  piece  of  gauze,  infil- 
trated with  orthoform,  to  the  external  raw  surfaces  left  by  cutting  otf  the 
external  htemorrhoids;  this  is  covered  with  a  good  pad  of  gauze  or  ab- 
sorbent cotton,  and  held  in  position  by  a  snug  T-bandage.  The  ortho- 
form  is  somewhat  antiseptic  in  its  action;  at  the  same  time  it  is  a  local 
anaesthetic  to  fresh  and  granulating  wounds;  it  obviates  the  necessity  of 
administering  opiates  after  the  operation,  and  is  by  far  the  most  com- 
fortable dressing  for  the  patient.  If  the  sphincter  is  thoroughly  relaxed 
and  has  no  tendency  to  recontract  immediately,  this  dressing  is  quite 
as  satisfactory  as  any  other.  In  some  cases,  however,  it  seems  impossible 
to  thoroughly  paralyze  the  sphincter  by  stretching;  and,  however  com- 
pletely the  latter  is  done,  one  will  find  by  the  time  the  operation  is  com- 
pleted that  this  muscle  has  already  begun  to  show  a  tendency  to  recon- 
tract. In  such  eases  the  operator  should  use  a  Pennington  tube,  which 
consists  of  a  piece  of  medium-sized  stiff  rubber  tubing  about  6  inches 
long,  attached  to  which  is  a  sheath  of  very  thin  rubber;  the  tube 
is  wrapped  with  iodoform  or  plain  gauze  until  its  size  is  sufficient 
to  keep  the  sphincter  well  dilated,  and  the  rubber  sheathing  is  then 
folded  over  this  gauze.  The  whole  is  then  introduced  for  about  4  inches 
into  the  rectum  with  the  open  end  of  the  sheath  downward,  orthoform 
having  been  dusted  upon  the  raw  surfaces  about  the  anus.  The  tube 
serves  to  allow  the  escape  of  any  gas  which  may  accumulate  in  the  rec- 
tum, to  control  bleeding  by  its  pressure,  and  to  maintain  the  dilatation 
of  the  sphincter,  while  the  rubber  sheath  prevents  granulations  from 
forming  in  the  meshes  of  the  gauze,  and  allows  the  plug  to  be  w^ithdrawn 
whenever  it  may  be  desirable  without  any  adhesion  or  pain.  Gauze  is 
then  packed  around  the  lower  end  of  this  tube  and  a  snug  T-bandage 
is  applied  through  which  the  end  of  the  tube  protrudes  in  order  to  pre- 
vent pressure  upon  the  latter.  A  large  safety-pin  is  fastened  through  the 
end  of  the  tube  in  order  to  prevent  its  escape  upward  into  the  rectum, 
and  thus  the  dressing  is  completed. 

As  a  rule  the  author  is  opposed  to  the  use  of  any  plug  or  tampon  in 
the  rectum,  but  in  the  class  of  cases  described  above  he  has  found  this 
method  of  Pennington's  to  be  of  great  service;  it  can  be  removed  on  the 
second  or  third  day,  or  it  may  be  allowed  to  come  away  with  the  first 
movement  of  the  bowels.  Eecently  we  have  used  bicarbonate  of  soda  in- 
stead of  orthoform  in  dressing  wounds  made  with  the  actual  cautery.  The 
prevention  of  pain  has  been  remarkable.  The  remedy  should  be  applied 
freely  to  the  operative  field  before  adjusting  the  tube  or  gauze  dressing. 

After-treatment. — Usually  a  hypodermic  injection  of  morphine  is 
given  before  the  patient  leaves  the  table,  and  this  is  all  that  is  necessary 
during  the  whole  course  of  treatment.  On  the  second  night  following 
the  operation  twenty  to  thirty  minims  of  fluid  extract  of  cascara  should 


HEMORRHOIDS— PILES  645 

be  administered;  when  the  bowels  feel  like  moving  two  ounces  of  sweet-oil 
should  be  injected  into  the  rectum.  This  may  be  done  through  the  tube, 
if  one  has  been  used,  and  then  the  latter  should  be  withdrawn.  x\fter  the 
movement  has  occurred,  an  enema  of  about  one  pint  of  boric-acid  solu- 
tion should  be  given,  which  immediately  comes  away  and  clears  the 
operative  field  of  any  small  fsecal  masses  which  may  have  adhered  to  it; 
this  should  be  repeated  daily  for  one  week,  regulating  the  amount  of 
laxative  to  the  needs  of  the  patient.  After  the  bowels  have  moved,  a 
small  piece  of  gauze  or  cotton  infiltrated  with  aristol  or  some  such  pow- 
der should  be  applied  to  the  anus  two  or  three  times  a  day  to  keep  it  dry. 
If  there  is  a  tendency  to  recontraction  and  spasm  of  the  sphincter,  the 
introduction  of  a  full-size  Wales  bougie  daily  will  relieve  it,  but  this  is 
very  rarely  necessary. 

The  time  for  complete  healing  after  this  operation  varies  from  two 
to  four  weeks,  the  average  being  about  twenty-one  days.  Patients  are 
allowed  to  get  out  of  bed  after  the  bowels  have  moved  on  the  third  day. 
They  can  generally  walk  about  without  any  distress,  but  sitting  will  be 
found  imcomfortable.  As  a  rule  they  leave  the  hospital  and  return  to 
their  homes  or  to  work  on  the  sixth  or  seventh  day.  They  are  allowed 
to  use  the  commode  even  for  the  first  movement  of  the  bowels,  and  are 
never  required  to  use  a  bedpan  unless  there  is  some  complication.  There 
is  often  some  bleeding  after  stools  for  the  first  week,  but  it  is  never 
alarming,  and  only  comes  from  the  granulating  surfaces.  It  gradually 
disappears,  and,  with  the  exception  of  a  little  moisture  from  the  dis- 
charge, the  patient  suffers  no  further  inconvenience. 

The  Ceushixg  Opekation. — Crushing  is  an  old  operation  for  hsem- 
orrhoids.  Formerly  it  was  the  practice  to  seize  the  whole  tumor  with  a 
powerful  flat- jawed  forceps  and  crush  it,  leaving  the  pulp  thus  formed 
to  slough  away.    This  method  is  now  obsolete. 

Chassaignac  conceived  the  idea  of  crushing  off  haemorrhoids  with 
his  ecraseur,  and  practised  it  to  some  extent;  but  the  operation  never 
became  popular,  and  is  not  done  at  present.  Later,  several  instruments 
were  devised  for  crushing  off  the  pile  at  its  base.  Among  them  was 
Benham's  crusher,  and  in  1880,  Pollock,  of  London,  made  a  strong  plea 
for  this  method  and  instrument  in  the  following  words: 

"  It  is  now  some  two  or  three  years  since  I  commenced  to  put  in  prac- 
tice these  views.  The  earlier  attempts  to  crush  the  base  of  the  pile, 
were  occasionally  partial  failures  as  regarded  the  perfect  freedom  from 
hgemorrhage.  Either  from  want  of  proper  construction  the  clamp  did 
not  effectually  spoil  the  tissues  at  the  base  of  the  piles;  or,  perhaps,  from 
too  much  of  the  protruding  mass  being  taken  up  at  a  time  to  enable  the 
clamp  to  act  efficiently,  or  from  some  other  unexpected  cause,  some 
bleeding  would  occur  after  the  clamp  was  removed,  the  pile  having  been 


646  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

cut  away;  and  this  had  to  be  dealt  with  by  ligature.  Seldom,  however, 
were  more  than  two  or  three  ligatures  necessary,  and  never  was  trouble- 
some or  recurring  hannorrhage  encountered.  As  successive  cases  con- 
tinued to  be  treated  in  this  manner,  any  defects  of  the  clamp  became 
manifest,  and  gradual  improvements  were  made.  Still,  the  theory  that 
crushing  the  base  of  the  pile  should  entirely  obviate  the  occurrence  of 
hasmorrhage  on  the  separation  of  the  pile  and  subsequent  removal  of 
the  clamp,  was  not  as  yet  fully  realized  by  the  results.  Sometimes  we 
had  no  bleeding;  sometimes  three  or  four  vessels  might  be  required  to 
be  ligatured.  But  still  the  one  satisfactory  result  observed  in  all  cases 
thus  treated  was  that  the  subsequent  pain  was  quite  an  insignificant 
matter.  It  is  not  wished  to  imply  in  this  statement  that  no  one  ever 
complained  of  pain;  but  in  contrast  to  the  pain  attendant  on  ligature, 
or  that  noticed  after  the  application  of  the  hot  iron,  certainly  that 
which  has  been  observed  after  this  system  of  rapid  crushing  may  almost 
be  said  to  be  a  minus  quantity.  One  patient  complained  of  pain  for 
about  three  hours.    In  all  cases  patients  have  expressed  themselves  free 


Fig.  209. — Allingham's  Hjemorrhoid  Crusher 


from  severe  pain,  and  many  have  hardly  complained  of  any  after  an  hour 
or  two.  One  who  had  some  years  previously  undergone  an  operation 
by  ligature,  expressed  his  extreme  gratification  at  the  almost  entire 
absence  of  even  discomfort  after  the  first  effects  of  the  ether  had  gone 
off  "  (The  Lancet,  vol.  ii,  p.  1,  1880). 

Allingham  states,  after  trying  Pollock's  method,  that  he  found  the 
instrument  did  not  crush  the  base  thoroughly,  and  that  more  or  less 
bleeding  always  resulted.  In  one  case  a  bad  concealed  haemorrhage  took 
place.  It  was  from  the  crushed  hemorrhoid,  and  flowed  upward  into 
the  bowel.  Some  hours  after  the  operation  the  patient,  being  seized 
with  a  desire  to  go  to  stool,  evacuated  a  large  quantity  of  arterial  blood, 
and  this  bleeding  was  continued  until  checked  by  cold-water  irrigation 
and  tamponing  of  the  rectum  with  wool  and  perchloride  of  iron. 

After  this  he  devised  a  crusher  (Fig.  209)  in  which  the  power  is 
exercised  by  a  screw.  To  use  this  instrument  a  special  form  of  forceps 
is  necessary  (Fig.  210).  He  calls  attention  to  the  importance  of  crushing 
the  haemorrhoids  longitudinally  and  not  transversely.  Pollock  crushed 
both  external  and  internal  hemorrhoids  by  his  method,  but  Allingham 


HEMORRHOIDS— PILES  647 

advised  making  an  incision  at  the  muco-cutaneous  border,  and  only 
crushing  the  internal  piles. 

Mr,  Charles  John  Smith,  of  Farrington  Dispensary,  has  devised  a 
modification  of  Allingham's  crusher  (Fig.  211)  which  appears  to  have 
some  advantages  over  the  latter  in  the  application  of  the  power,  and  in 
the   fact   that   the   in- 
strument is  applied  to 
the  pile  instead  of  the 
latter    being    dragged 
through    a    fenestrum 

,,       .       ,  ,       TT  Fig.  210. — Allingham's  Forceps  for  Use  in  Crushing 

m  the  instrument.     He  Operation. 

advocates  crushing  the 

pile  transversely  to  the  axis  of  the  gut,  arguing  that  dilatation  being 
in  this  line,  there  will  be  less  danger  of  the  wound  being  torn  open. 
This  danger,  however,  is  not  to  be  compared  with  that  of  stricture, 
which  is  never  produced  by  the  former  method. 

Ten  years  since,  being  impressed  with  the  idea  that  the  clamp  would 
effectually  control  the  bleeding  following  excision  of  haemorrhoids,  and 
that  granulation  would  start  up  more  readily  there  being  no  eschar 
from  the  cautery  to  come  away,  the  author  made  some  experiments  with 
this  method,  using  the  old-style  hgemorrhoidal  clamp  with  mortised, 
serrated  edges  and  long,  strong  handles.  Both  external  and  internal 
piles  were  crushed  off;  they  were  caught  with  the  hemorrhoidal  forceps, 
dragged  out,  and  the  clamp  applied  at  the  point  where  the  tumor  joined 
the  mucous  or  muco-cutaneous  tissue,  then  with  a  slow,  chewing  motion 
the  base  of  the  tumor  was  crushed  until  a  sort  of  pedicle  or  neck  was 
formed,  outside  of  which  it  was  cut  off  with  scissors.  Frequently  it  was 
possible  to  remove  the  tumor  by  the  crushing  power  of  the  clamp  alone; 
especially  was  this  the  case  in  external  haemorrhoids.  The  results  justi- 
fied in  a  measure  all  that  Pollock  claimed  for  the  method.  After  opera- 
ting upon  25  cases  by  this  method,  a  hsemorrhoid  slipped  out  of  the 

clamp  after  the  summit  had  been  cut 
off  in  an  operation  by  the  clamp  and 
cautery.  It  is  true  that  the  pile  was 
only  partially  crushed  in  this  instance, 
but  the  author  was  so  impressed  with 

Fig.  211. — Smith's  Hemorrhoid  ,,  -n  -t,  i>  i  -11 

^^^gjjj^  the  possibility  ot  such  an  accident  oc- 

curring after  the  crushing  method  that 
he  has  never  done  the  operation  for  internal  hemorrhoids  since.  In 
external,  inflammatoiy,  or  connective-tissue  hasmorrhoids  this  method 
is  still  employed.  The  operation  may  be  done  in  these  cases  under  the 
influence  of  cocaine.  The  crushing  brings  the  muco-cutaneous  edges  so 
accurately  together  that  one  can  hardly  see  that  any  tissues  have  been 


648  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

removed.  After  having  crushed  the  tabs  off,  collodion  should  be  applied, 
and  the  parts  will  often  heal  just  as  if  the}^  had  been  sutured  b}^  the 
subcutaneous  method.  'No  hsemorrhage  follows  this  method  in  external 
haemorrhoids,  and  very  slight  inflammation  ever  occurs.  The  cauteriza-' 
tion  of  the  stump,  however,  is  a  safeguard  against  hasmorrhage  and 
adds  an  aseptic  element  which  the  crushing  operation  does  not  do. 

Recently  some  operators  have  been  using  the  angeiotribe  in  carrying 
out  the  crushing  operation.  While  this  method  is  very  effectual,  the 
size  and  weight  of  the  instrument  seem  to  preclude  the  possibility  of 
accurately  applying  it  to  anything  except  very  large  masses.  If  an  in- 
strument of  this  t3-pe,  but  less  cumbersome,  could  be  devised,  there  is  no 
doubt  that  it  would  prove  very  useful,  but  none  of  those  in  use  at 
present  are  superior  to  the  old  Kelsey  clamp  used  in  the  method  which 
has  been  described. 

Excision. — For  many  years  there  have  been  advocated  from  time  to 
time  divers  methods  of  complete  excision  of  ha?morrhoidal  tumors.  Es- 
march,  Dupuytren,  Brodie,  and  Cooper  excised  the  piles,  tied  the  bleed- 
ing vessels  and  left  the  open  wounds  to  heal.  Pennington  (Internat. 
Jour,  of  Surgery,  1900,  p.  360)  has  revived  this  method;  but  most  op- 
erators consider  it  a  more  surgical  procedure  to  excise  the  tumors  and  sew 
the  edges  of  the  mucous  membrane  together,  thus  closing  the  wounds. 

Whitehead  Method.— In  1882,  Mr.  Walter  Wliitehead,  of  Manchester, 
after  a  brief  and  unsatisfactory  experience  with  the  ligature,  and  clamp 
and  cautery,  introduced  total  excision  of  the  hsemorrhoidal  area — i.  e., 
the  lower  inch  and  a  half  of  the  mucous  membrane  of  the  rectum  (Brit. 
Med.  Jonr.,  1882,  vol.  i,  p.  149). 

In  his  first  operation  (Brit.  Med.  Jour.,  1882,  vol.  i,  p.  149)  he  left 
strips  or  islets  of  mucous  membrane  between  the  dissected  areas  in  order 
to  prevent  circular  stricture  of  the  lower  end  of  the  rectum  if  primary 
union  failed  to  take  place.  His  final  and  perfected  technique,  that 
which  is  now  accepted  and  taught  under  his  name,  does  not  embrace 
this  feature.     He  described  it  as  follows  (the  italics  are  ours): 

"  1.  The  patient,  previously  prepared  for  the  operation  and  under 
the  complete  influence  of  an  ana?sthetic,  is  placed  on  a  high,  narrow 
table  in  the  lithotomy  position,  and  maintained  in  this  position  either 
by  a  couple  of  assistants  or  by  Clover's  crutch. 

"  2.  The  sphincters  are  thoroughly  paralyzed  by  digital  stretching, 
so  that  they  have  '  no  grip,'  and  permit  the  haemorrhoids  and  any  pro- 
lapse there  may  be  to  descend  without  the  slightest  impediment. 

"3.  By  the  use  of  scissors  and  dissecting  forceps,  the  mucous  mem- 
brane is  divided  at  its  juncture  with  the  shin  round  the  entire  circum- 
ference of  the  bow^el,  every  irregularity  of  the  skin  being  carefully  fol- 
lowed. 


HEMORRHOIDS— PILES  649 

"  4.  The  external  and  the  commencement  of  the  internal  sphincters 
are  then  exposed  by  a  rapid  dissection,  and  the  mucous  membrane  and 
attached  hsemorrhoids,  thus  separated  from  the  submucous  bed  on  which 
they  rested,  are  pulled  bodily  down,  any  undivided  points  of  resistance 
being  snipped  across,  and  the  hsemorrhoids  brought  below  the  margin 
of  the  skin. 

"  5.  The  mucous  membrane  above  the  haemorrhoids  is  now  divided 
transversely  in  successive  stages,  and  the  free  margin  of  the  severed 
membrane  above  is  attached,  as  soon  as  divided,  to  the  free  margin  of 
the  skin  below  by  a  suitable  number  of  sutures.  The  complete  ring  of 
pile-bearing  mucous  membrane  is  thus  removed. 

"  Bleeding  vessels  throughout  the  operation  are  twisted  on  divi- 
sion." 

Mr.  Whitehead  lays  stress  upon  the  point  that  the  incisions  are 
made  entirely  in  the  mucous  membrane,  but  one  may  be  misled  by  his 
references  to  cutting  and  suturing  the  "  margin  of  the  skin."  He  says: 
"  It  is  important  that  no  skin  should  be  sacrificed,  however  redundant 
it  may  appear  to  be,  as  the  little  tags  of  superfluous  skin  soon  contract 
and  eventually  cause  no  further  inconvenience."  He  states  that  there 
is  little  difficulty  in  separating  the  piles  from  the  sphincters,  and  that 
during  this  separation  and  dissection  there  is  practically  no  haemorrhage, 
the  dissection  being  made  by  a  raspatory  or  dull,  .curved  scissors,  or  with 
the  fingers.  There  are  certain  points  around  the  rectum  to  which  the 
attachment  is  closer  than  at  others,  on  account  of  the  passage  of  the 
branches  of  the  middle  hgemorrhoidal  arteries  through  the  muscle  and 
into  the  mucous  membrane.  These  points  have  to  be  snipped  with 
scissors. 

Mr.  Whitehead  uses  no  ligatures  to  control  the  arteries,  but  simply 
seizes  and  twists  them  with  artery  forceps  as  he  makes  his  transverse 
section  of  the  mucous  membrane.  He  says:  "  I  have  often  operated  upon 
severe  cases  and  not  found  it  necessary  to  twist  a  single  vessel,  and  very 
frequently  only  one  or  two."  In  the  300  cases  reported,  he  did  not  have 
a  single  instance  of  secondary  haemorrhage,  and  therefore  considers  that 
this  complication  need  scarcely  be  considered  in  the  operation.  Before 
closing  the  wound,  he  insufflates  iodoform  between  the  raw  surfaces,  in 
order  to  control  any  oozing  which  may  exist.  He  uses  carbolized  silk 
sutures,  and  never  takes  out  the  stitches.  An  ice-bag  is  kept  upon  the 
rectum  for  the  first  few  days,  and  the  bowels  are  moved  upon  the  fourth 
day.  The  patient  sits  up  on  the  same  day,  and  is  alloA\'ed  to  resume  his 
work  in  two  weeks.  The  pain  following  this  operation  differs  according 
to  the  personal  equation.  Some  patients  have  absolutely  none,  while 
others  suffer  from  burning  pain  in  the  parts,  aching  in  the  back,  or 
throbbing  and  fulness  in  the  rectum.. 


650 


THE  ANUS,  RECTUM,   AND   PELVIC  COLON 


He  claims  for  the  operation,  first,  that  it  is  the  most  natural  method; 
second,  it  requires  no  special  instruments;  third,  it  produces  a  radical 
cure;  fourth,  it  is  as  free  from  risks  as  any  other  operation;  fifth,  the 
pain  following  it  is  less  severe  than  that  following  other  operations  for 
the  same  condition;  and,  finally,  that  the  loss  of  blood  at  the  time  of  the 
operation  is  inconsiderable,  and  the  dangers  of  secondary  haemorrhage 
are  decidedly  less  than  after  other  operations.  We  have  thus  given 
largely  in  Mr.  "Whitehead's  own  words  the  description  of  his  operation, 
the  grounds  upon  which  it  is  based,  and  his  conclusions.  That  his  ex- 
periences are  not  borne  out  by  the  majority  of  the  operators  in  this 
country  and  in  Europe  is  well  known  to  the  profession.  His  statement 
that  the  time  required  is  short  and  the  hemorrhage  at  the  time  of  the 
operation  is  inconsiderable  has  not  been  the  experience  of  those  who 
attempt  the  method  according  to  his  technique. 

The  large  majority  of  operators  object  to  the  method  on  account 
of  the  amount  of  blood  lost,  the  length  of  time  it  takes  to  perform  it, 
the  uncertainty  of  primary  union  between  the  cut  edges,  the  danger 
of  stricture  following,  and,  finally,  on  account  of  the  fact  that  this 
operation  removes  certain  anatomical   structures  which  are   supposed 

to  have  functions 
necessary  to  the 
healthy  condition 
of  the  rectum.  The 
fact  that  it  re- 
moves the  tactile 
or  sensitive  mar- 
gin of  the  anus, 
the  crypts  of  Mor- 
gagni,  and  the  pa- 
pillae of  the  rec- 
tum, is  held  by 
some  to  take  away 
the  power  of  con- 
trol, or  rather  the 
sense  oi-  warning 
as  to  when  a  move- 
ment of  the  bowel 
is  likely  to  occur; 
this  same  result 
may  follow  both  the  ligature  and  the  clamp-and-cautery  operations, 
and  does  not  occur  in  any  larger  percentage  of  operations  done  after 
AVhitehead's  method.  The  time  it  takes  to  do  the  operation  and  the 
danger  of  subsequent  stricture  are  the  chief  objections  to  it;  the  amount 


Fig. 


212. — First  Step  ix  Modified  Whitehead  Opeeatimx 
Hjimorrhoids. 


HEMORRHOIDS— PILES 


651 


of  blood  lost,  while  not  alarming,  is  anno}dng  and  excessive  compared 
with  that  in  operations  by  clamp  and  cautery  or  the  ligature.  Ee- 
cently,  by  modifying  the  technique,  a  great  saving  in  time  and  loss 
of  blood  has  been  effected. 

This  modification  is  based  on  the  fact  that  the  blood-vessels  and 
submucous  tissue  can  be  easily  peeled  off  from  the  muscular  wall  of  the 
gut  from  above  downward. 

The  sphincters  having  been  thoroughly  stretched,  an  incision  is 
made  through  the  mucous  membrane  at  the  posterior  commissure  of 


Fig.  213. — Second  Step  ev  Modified  "Whitehead  OPEBATioif. 


the  rectum  (Fig.  212),  and  with  a  blunt-pointed  scissors,  curved  on  the 
flat,  dull  dissection  is  carried  uj)ward  to  the  superior  margin  of  the 
internal  sphincter;  with  a  boring  motion  the  instrument  is  insinuated 
between  the  mucous  membrane  and  this  muscle,  and  gradually  worked 
to  one  side  and  downward  until  it  comes  to  the  muco-cutaneous  border 
of  the  anus  (Fig.  213);  little  by  little  the  htemorrhoidal  mass  is  thus 
loosened  from  its  muscular  attachment  and  peeled  out  of  its  resting- 
place,  just  as  an  orange  can  be  peeled  from  its  skin.  Having  accom- 
plished this  upon  one  side,  the  instrument  is  turned  to  the  opposite 
side  and  the  same  process  is  carried  out.  The  only  point  at  which 
any  difficulty  will  be  met  in  this  procedure  is  at  the  anterior  commis- 
sure of  the  rectum. 

Having  thus  loosened  the  whole  hfemorrhoidal-bearing  area  from 
its  attachment  to  the  muscular  wall,  the  mucous  membrane  is  cut  just 


652 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


above  the  muco-ciitaneous  margin,  and  the  hemorrhoidal  area  will  thus 
be  left  loose  in  the  rectum.  An  incision  is  then  made  in  the  mu- 
cous membrane  at  the  posterior  commissure,  extending  as  high  up  as 
the  hgemorrhoids  extend.  Each  flap  thus  formed  is  caught  by  clamps, 
and  the  tube  of  mucous  membrane,,  with  the  haemorrhoids  attached, 
is  dragged  down.  It  is  loosened  above  by  pressure  with  gauze  or  dull- 
pointed  scissors  until  the  healthy  portion  can  be  brought  down  to  the 
margin  of  the  anus  without  tension.  It  is  then  cut  off  transversely 
above  the  haemorrhoidal  mass,  step  by  step,  and  sutured  to  the  edge 
of  the  muco-cutaneous  wound  below  (Fig.  214). 

The  haemorrhage  during  dissection  is  very  slight,  and  the  blood- 
vessels cut  in  the  transverse  section  of  the  mucous  membrane  are  easily 
controlled  by  the  sutures  which  are  applied  immediately  thereafter; 
there  is  no  occasion  to  either  twast  or  tie  them.    A  mattress-stitch  thrown 


Fig.  214. — Thiku  Step  in  Modified  Whitehead  Operation. 


around  the  artery  will  control  it  perfectly.  The  haemorrhage  and  the 
time  of  the  operation  are  materially  reduced  by  this  method,  and  the 
same  end  is  accomplished  as  is  designed  by  the  Whitehead  operation. 
The  close  attachment  of  the  mucous  membrane  to  the  muscular  wall  at 
the  anterior  commissure  of  the  rectum  requires  some  dissection  to 
loosen  it,  but  this  is  never  difficult.  The  wound  is  sutured  with  large- 
si?ed  catgut  in  continuous  sutures  running  from  the  posterior  to  the 


HEMORRHOIDS— PILES 


663 


Fi&.  215.- 


anterior  commissure  upon  each  side  (Fig.  215).  The  large-sized  catgut 
is  of  importance  because  it  is  less  likely  to  tear  through  than  fine 
silk  or  small  suturing  material.  Chromicized  gut  and  silk  are  objec- 
tionable, in  that  they  both  remain  in  the  parts  too  long;  they  require 
to  be  removed  or  must  cut  their  way 
out,  leaving  small  fissure-like  cracks 
about  the  margin  of  the  anus,  and 
sometimes  they  cause  little  stitch- 
hole  abscesses  which  are  very  an- 
noying and  retard  recovery.  In  lOT 
operations  by  this  method  the  re- 
sult has  been  simply  perfect  in  105; 
the  catheter  has  been  used  in  only 
2  cases,  and  morphia  has  been  ad- 
ministered only  three  times  in  the 
entire  series.  In  1  case,  through  a 
mistake  of  the  house  surgeon,  an 
unfortunate  result  occurred.  Xot 
being  present  at  the  operation  he 
supposed  that  the  clamp  and  cau- 
tery had  been  employed,  and  no- 
ticing a  somewhat  unusual  oozing 
from  the  parts,  determined  to  pack 

the  rectum  and  control  it.  Without  introducing  a  speculum,  he 
forced  a  large  mass  of  iodoform  gauze  through  the  anus  and  thus 
tore  loose  all  of  the  sutures  and  forced  the  mucous  membrane  up- 
ward into  the  rectum.  This  was  done  about  two  hours  after  the 
operation,  and  an  alarming  secondary  hemorrhage  occurred.  The 
author  was  called  to  the  patient,  and  on  learning  what  had  taken 
place  immediately  reansesthetized  him,  washed  out  the  parts  as  well 
as  possible,  and  applied  the  sutures  for  the  second  time.  As  might 
have  been  expected,  primary  union  failed  to  occur,  and  a  cicatricial 
stricture  resulted  which  required  the  use  of  bougies  for  a  year  after- 
ward in  order  to  prevent  most  serious  contraction.  In  the  other  case 
a  result  occurred  which  is  inexplicable;  the  operation  was  performed 
as  above  described,  primary  union  took  place,  and  the  patient  reported 
himself  as  having  no  discomfort  and  feeling  perfectly  well  for  three 
months  thereafter.  He  disappeared  from  view,  and  at  the  end  of  sis 
months  he  was  recommitted  to  the  workliouse  where  he  had  been 
treated.  Upon  examination  of  the  rectum  a  cicatricial  stricture  of 
marked  character  was  found  about  2  inches  above  the  anal  margin. 
The  dissection  did  not  extend  to  any  such  height;  the  anus  and  the 
rectum  at  the  site  of  the  suture  were  patulous  and  of  normal  caliber; 


Modified  "Whitehead  Opera- 
tion Completed. 


654  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

the  patient  had  no  specific  history  or  other  evidence  of  syphilis,  and 
therefore  the  condition  could  not  be  attributed  to  it.  The  author  is 
unable  to  explain  it. 

The  design  of  this  operation  has  in  it  no  originality;  it  is  simply  a 
short  method  of  accomplishing  what  Whitehead  advocated.  The  time 
occupied  in  the  operation  varies  from  ten  to  fifteen  minutes,  which  is 
a  matter  of  no  inconsiderable  importance,  inasmuch  as  a  large  number 
of  the  operations  mentioned  have  been  done  upon  patients  above  the 
age  of  sixty  years.  In  a  number  of  cases  the  wound  failed  to  heal  at 
all  points  by  primary  union,  and  small  granulating  spots  were  left, 
but  these  healed  in  due  time,  and  there  was  no  appreciable  retraction 
of  the  mucous  membrane.  When  large  skin-tabs  are  present  they  are 
cut  off  with  scissors  and  the  edges  are  sutured  together;  or  they  are 
crushed  off  with  the  clamp  and  collodion  is  applied,  as  before  described, 
after  the  operation  on  internal  haemorrhoids  has  been  completed.  In 
none  of  these  cases  has  there  been  any  incontinence  or  loss  of  sensibility 
in  the  rectum. 

Instead  of  removing  the  entire  pile-bearing  area  or  lower  inch  of  the 
mucous  membrane  of  the  rectum,  as  is  done  in  the  Whitehead  operation, 
many  operators  prefer  to  take  the  pile  tumors  individually,  excise  them 
and  suture  the  edges  of  the  mucous  membrane  together.  Gallant  (Mat- 
thews Medical  Quarterly,  October,  1894)  states  that  Outerbridge  had 
followed  this  plan  since  1888  with  great  success.  The  author  has  applied 
this  method  a  number  of  times;  he  has  not  observed  that  it  shortened 
the  course  of  treatment  or  gave  any  less  pain  to  the  patient  than  the 
clamp-and-cautery  operation;  moreover,  it  requires  considerable  more 
time  than  the  latter  operation,  and  may,  as  he  has  seen  in  one  case,  be 
followed  by  stricture  of  the  rectum. 

Earle  (Matthews  Medical  Quarterly,  January,  1896),  Parkhill 
(International  Journal  of  Surgery,  May,  1900),  and  Mason  have  each 
devised  instruments  for  this  operation  and  also  to  facilitate  the 
Whitehead  method;  the  author's  experience  is  confined  to  the  Earle 
instrument. 

Earle' s  Method. — The  patient  is  prepared  for  the  operation  as  in  the 
other  methods;  the  sphincter  is  stretched  and  the  parts  thoroughly 
cleansed.  If  the  ha?morrhoidal  tumors  are  isolated,  each  is  seized,  in 
order,  with  the  haemorrhoidal  forceps,  dragged  down  and  then  grasped 
in  the  line  of  the  long  axis  of  the  gut  by  the  Earle  clamp  (Fig.  316)  ;  a 
running  suture  is  then  introduced  through  the  fold  of  mucous  membrane 
just  above  the  grasp  of  the  clamp  and  tied  around  this  fold,  thus  includ- 
ing the  artery  supplying  the  pile;  the  free  portion  of  the  haemorrhoid 
is  then  cut  off  little  by  little,  and  the  running  suture  is  carried  round 
and  round  the  clamp  (Fig.  217)  through  the  base  of  the  tumor  until 


S^MORRHOiDS— PILES 


655 


the  lower  end  of  the  hgemorrhoid  is  reached ;  the  clamp  is  then  loosened 
and  withdrawn,  the  running  suture  is  tightened  and  tied,  and  the  whole 
wound  is  thus  closed  without  any  loss  of  blood.  If  the  whole  circumfer- 
ence of  the  rectum 
is  involved  in  the 
hemorrhoidal  pro- 
cess the  method  is 
modified  as  fol- 
lows : 

The  tissues  are 
seized  at  four  or 
five  points  in  the 
circumference  of  the 
anus  at  the  level  of 
Hilton's  white  line  and  dragged  down  until  the  healthy  mucous 
membrane  is  brought  into  view;  an  incision  is  then  made  through  the 
mucous  membrane  at  the  posterior  commissure  to  the  height  of  the  tis- 
sues   to    be    removed.    .„.^ 


Fig.  216 


r 


The  mucous  membrane 
at  the  upper  angle  of 
this  incision  and  the 
skin  at  the  lower  angle 
are  brought  together 
with  a  large-sized  cat- 
gut suture.  The  hasm- 
orrhoidal  clamp  is  then 
placed  upon  the  tissues 
to  be  removed  parallel 
with  the  circumference 
of  the  anus,  and  the 
summit  of  the  tumor  is 
excised  and  the  wound 
sutured  as  in  the  case  of 
the  isolated  tumors, 
"  thus  imitating  the 
work  done  by  the 
Whitehead  operation  in 
almost  a  bloodless  man- 
ner, without  exposing 
the  raw  surface  to  in- 
fection." Earle  recommends  the  use  of  Hibbs'  double  curved  scissors 
to  excise  the  tumor,  and  has  recently  stated  that  Hibbs'  modification  of 
his  forceps  is  more  suitable  for  the  second  method  of  operating.     As  in 


Fig.  217. — Earle's  Operation. 


656 


THE   AXUS,   RECTUM,   AXD   PELVIC   COLOX 


the  Whitehead  operation,  large  plain  catgut  is  recommended  for  the 
sutures. 

The  author  has  occasionally  found  some  difficulty  in  pulling  the  loops 
of  thread  tight  after  the  forceps  has  Ijeen  removed  on  account  of  their 
sinking  into  the  tissues.  To  avoid  this  he  has  added  to  the  Earle  forceps 
a  small  hook  (Fig.  218),  over  which  each  loop  of  the  suture  is  thrown 
until  all  are  placed  in  position.  By  this  means  the  suture  can  he  accu- 
rately and  surely  tightened  without  undue  dragging  upon  the  wound. 

In  cases  with  one  or  two  pedunculated  haemorrhoids  and  relaxed 
sphincters,  this  operation  can  he  done  under  the  influence  of  cocaine  in 
one's  office,  and  the  patient  allowed  to  go  home  and  ahout  his 
business  on  the  following  day.  The  operation  is  not  altogether  appli- 
cable to  those  cases  in  which  there  is  a  general  varicosity  of  the  entire 


Fig.  218. — LiiiixiiD  Excision  of  Hemorrhoids. 


rectum.     In  properly  selected  cases,  however,  the  results  obtained  by  it 
have  been  all  that  could  be  desired. 

From  a  surgical  point  of  view  excision  is  certainly  an  attractive 
operation,  but  it  is  not  so  simple  as  the  ligature  or  the  clamp  and 
cautery.  The  pain  and  dangers  of  haemorrhage,  either  primary  or 
secondary,  can  not  be  considered  as  serious  objections;  the  complica- 
tions  and  dangers  from   the   operation   consist  in   failure   of   primary 


HEMORRHOIDS— PILES 


657 


union,  the  destruction-  of  sensitive  organs  of  the  lower  end  of  the  rectum, 
and  in  the  production  of  circular  stricture  at  the  anus.  The  writer  has 
seen  seven  strictures  caused  by  this  operation,  and  has  come  to  the  con- 
clusion that  it  is  not  a  safe 
one  in  the  hands  of  general 
practitioners,  however  suc- 
cessful it  may  be  in  those 
of  an  expert,  rapid  opera- 
tor. Two  other  complica- 
tions have  been  observed 
which  can  not  properly 
be  charged  against  the 
method.  The  first  was  an 
exstrophy  of  the  rectum 
due  to  the  incision  having 
been  made  in  the  skin  out- 
side of  the  anus,  and  the 
mucous  membrane  ( Fig. 
219)  sutured  to  its  edges. 
Through  this  faulty  tech- 
nique the  membrane  is  ex- 
posed to  constant  friction 
from  the  clothing  and 
from  the  buttocks  in  walk- 
ing, the  surrounding  skin 
is  moist  and  excoriated, 
and  there  is  a  disgusting 
feculent  odor  from  the 
parts.     This  complication  may  be  remedied  as  follows : 

A  star-shaped  incision  is  made  in  the  skin  around  the  anus;  the 
points  and  the  protruding  mucous  membrane  are  dissected  loose,  the 
latter  is  shoved  up  to  its  natural  position  and  fixed  there  by  buried 
sutures;  finally  the  skin  edges  are  sutured  together,  and  a  Pennington 
tube  inserted.  The  other  deplorable  result  was  exactly  the  opposite 
to  this,  in  that  the  mucous  membrane  had  not  been  dissected  suffi- 
ciently high  up,  the  skin  had  been  loosened  around  the  lower 
edge  of  the  incision,  and  when  the  parts  had  united  the  cutaneous 
tissue  was  dragged  upward  into  the  rectum,  where  it  was  kept 
moist  by  the  mucous  secretion,  and  a  sort  of  sodden,  washer-woman's- 
hand  condition  of  the  skin  was  produced,  which  soon  became  excoriated, 
and  discharged  a  feeident  secretion  which  burned,  stung,  and  irritated 
the  patient  until  life  was  almost  unbearable.  The  author  has 
operated  upon  2  cases  for  this  complication  by  dissecting  the  skin  and 
43 


Fi&, 


219. — Exstrophy    of   Mucous    Membrane    fol- 
lowing Faulty  Whitehead  Operation. 


658  THE   ANUS,  RECTUM,   AND   PELVIC  COLON 

mucous  meml)rano  loose  and  cutting  off  that  portion  which  was  drawn 
upward  into  the  rectum,  afterward  hringing  the  normal  mucous  mem- 
brane down  and  suturing  it  to  the  healthy  skin  about  the  margin  of 
the  anus.  The  results  have  been  an  improvement  in  the  patient's 
condition,  but  not  altogether  satisfactory. 

The  American  Operation. — There  has  been  a  great  deal  of  confusion 
with  regard  to  the  use  of  this  term.  Some  authors  apply  it  to  the 
transfixion  method  of  ligature.  In  the  western  part  of  the  United 
States  it  is  understood  to  mean  a  modification  of  the  Whitehead  opera- 
tion introduced  by  Pratt,  of  Chicago.  This  procedure  differs  from  the 
ordinary  "Whitehead  operation  in  two  features:  first,  the  mucous  mem- 
brane is  cut  transversely  above  the  haemorrhoids  and  dissected  down- 
ward; second,  it  premeditatedly  removes  all  the  redundant  skin  and 
muco-cutaneous  tissue  around  the  margin  of  the  anus.  The  operation 
thus  done  drags  the  internal  sphincter  downward,  forming  a  collar  or 
roll  around  the  lower  end  of  the  rectum,  and  it  also  brings  the  mucous 
membrane  outside  of  the  anus,  producing  a  sort  of  exstrophy  ani. 
The  whole  procedure  is  a  bad  modification  of  the  A\liitehead  opera- 
tion; it  does  not  represent  the  opinion  or  practice  of  American  sur- 
geons, and  is  in  no  wise  entitled  to  this  name. 

The  injection  method  might  very  properly  be  called  the  American 
method,  for  it  originated  in  this  country.  Eoux,  of  Lausanne,  speaks 
of  it  as  such.  He  describes  it,  however,  as  a  major  operation  done 
under  anaesthesia  and  after  forcible  divulsion  of  the  sphincters.  The 
particular  features  of  the  operation  as  done  in  America  are:  it  requires 
no  anaesthetics,  it  gives  little  pain,  and  does  not  confine  the  patient  after 
the  first  few  hours.  Were  the  method  always  as  carefully  and  thor- 
oughly carried  out  with  regard  to  its  antiseptic  details  as  is  described 
by  Eoux,  this  operation  would  be  a  credit  to  America  or  any  other 
country.  It  is  certainly  more  entitled  to  the  appellation  than  is  that 
parody  on  excision  described  above  and  so  often  called  the  American 
operation. 

Strangulated  H.emokrhoids. — Strangulation  of  hemorrhoids  may 
occur  in  two  ways:  first,  by  the  prolapsed  mass  being  grasped  by  a  spas- 
modic sphincter  which  constricts  the  circulation;  second,  by  an  inflam- 
matory action  set  up  through  abrasion  and  infection  of  the  mucous 
membrane  of  the  rectum,  through  which  the  vessels  of  the  ha?mor- 
rhoidal  tumor  are  obstructed.  The  distinction  between  these  two 
causes  is  very  important,  as  in  one  we  are  able  by  dilatation  of  the 
sphincter  to  relieve  the  strangulation,  while  the  other,  being  due  to  an 
inflammatory  process,  must  be  treated  upon  an  entirely  different  basis. 
In  the  first  method  it  may  occur  as  an  acute  condition  in  patients 
whose  piles  have  never  prolapsed  before,  but  have  been  brought  down 


HiEMOKRHOIDS— PILES 


659 


at  the  time  by  unusual  straining,  in  lifting,  or  in  the  efforts  to  have 
a  movement  of  the  bowels.  Again,  the  hgemorrhoids  may  have  been 
in  the  habit  of  prolapsing  for  years.  At  first,  perhaps,  they  are  spon- 
taneously reduced;  later  on  the  patient  finds  it  necessary  to  reduce 
them  himself;  but  finally,  after  a  period  of  constipation,  or  some  irrita- 
tion at  the  margin  of  the  anus,  the  sphincter  becomes  spasmodic,  the 
tumors  are  constricted  by  it,  and  strangulation  ensues.  Strangulation 
occurs  in  only  internal  and  mixed  haemorrhoids  (Fig.  220);  in  the  former 
it  is  not  very  painful,  and  sometimes  proceeds  to  gangrene  before  the 
patient  realizes  there  is  any  serious  disturbance;  in  the  mixed  variety 
it  is  very  painful.  Efforts  at  reduction  in  the  latter  cases  should 
be  very  careful- 
ly made,  because 
only  a  part  of  the 
swollen  and  con- 
stricted mass  can 
be  put  inside  of 
the  rectum,  and 
any  attempt  to  put 
the  rest  above  the 
external  sphincter 
will  not  only  be 
useless,  but  will 
aggravate  the  con- 
dition. AYhere  the 
strangulation  has 
persisted  for  some 
time,  the  tumors 
may  slough  off.  In 
this  way  spontane- 
ous cure  may  re- 
sult, but  general- 
ly it  is  very  in- 
complete, because  only  portions  of  the  mass  slough  away,  and  little,  irri- 
table, bleeding  stumps  remain  which  are  the  source  of  much  annoyance, 
and  sometimes  of  considerable  ha?morrhage.  This  result  may  occur  just 
as  well  in  cases  of  inflammatory  strangulation  as  in  those  due  to  constric- 
tion of  the  sphincter  muscles.  The  author  does  not  agree  with  the  au- 
thorities who  hold  that  if  sloughing  has  once  commenced  in  a  hemor- 
rhoid nothing  more  is  to  be  done  except  to  place  a  charcoal  poultice  on 
the  parts  and  let  the  gangrene  proceed;  the  best  results  are  obtained  in 
these  cases  by  immediate  radical  operation  at  the  very  earliest  possible 
time  after  strangulation  has  occurred,  whether  there  be  gangrene  or 


Fig.  220. — SxRANGrLATED  H-emoerhoids. 


660  THE  ANtJS,  RECTUM,  AND  PELVIC  COLON 

not.  "WHien  the  sloughing  is  incomplete,  the  patient  must  suffer  more 
or  less  pain  and  danger  from  haemorrhage  while  the  process  is  going 
on.  It  seems,  therefore,  that  it  is  much  wiser  to  anaesthetize  the 
patient,  stretch  the  sphincter,  and  remove  all  the  gangrenous  and  septic 
material.  One  may  say  that  cutting  away  the  gangrenous  material 
only  opens  the  way  to  septic  infection.  This  would  be  true,  perhaps, 
if  the  incisions  were  made  with  sharp  instruments,  but  when  made 
with  a  clamp  and  the  stump  cauterized,  all  absorbent  vessels  are  her- 
metically sealed,  and  little  or  no  possibility  of  septic  absorption  re- 
mains. There  may  be  some  excuse  for  not  operating  upon  a  strangu- 
lated hemorrhoid  when  it  is  simply  congested  and  inflamed,  and  can 
be  reduced  by  proper  manipulation;  but  there  is  none  whatever  for 
leaving  a  mass  of  rotten,  gangrenous  tumors  to  macerate  and  drop 
away  when  they  can  be  radically  and  safely  removed  by  surgical  opera- 
tion. Haemorrhoids  which  prolapse  may  become  turgid  and  swollen, 
and  yet  not  strangulated  (Plate  IV,  Fig.  4).  In  such  a  case,  if  opera- 
tion is  not  possible  at  the  time,  the  patient  should  be  placed  with  his 
hips  elevated,  compresses  soaked  in  hot  water  or  boroglyceride  should 
be  applied  to  the  parts,  and  a  hot-water  bag  laid  over  these  to  maintain 
the  heat,  encourage  the  circulation,  and  prevent  sloughing.  Cold  appli- 
cations are  unadvisable  in  such  cases. 

Patients  consent  much  more  readily  to  have  an  operation  for  piles 
when  they  are  suffering  pain  and  distress  from  prolapse  or  strangula- 
tion than  at  other  times.  In  fact,  many  who  have  persistently  refused 
to  have  anything  done  so  long  as  their  haemorrhoids  were  in  a  quiescent 
state,  eagerly  seek  operative  relief  when  these  conditions  develop. 

Febrile  and  constitutional  symptoms  are  associated  with  both  varie- 
ties of  strangulation,  but  they  are  more  marked  in  the  inflammatory 
than  in  the  muscular;  the  pain  is  also  greater  in  the  inflammatory 
kind.  Strangulation  may  be  due  to  inflammation,  and  yet  at  the  same 
time  complicated  by  constriction  of  the  sphincter  muscles.  In  these 
cases  the  inflammation  occurs  first,  the  haemorrhoids  become  swollen, 
strangulated,  and  prolapsed,  and  then  the  irritation  causes  spasm  of 
the  sphincter,  and  thus  there  is  a  double  condition  to  deal  with.  If 
seen  before  ulceration  or  gangrene  begin,  almost  any  mass  of  prolapsed 
haemorrhoids  can  be  reduced  under  the  influence  of  general  anaesthesia. 
If,  however,  the  patient  must  be  anaesthetized  in  order  to  'have  the 
tumors  reduced,  there  are  scarcely  any  circumstances  which  would  con- 
traindicate  the  radical  and  rapid  removal  of  the  mass.  The  application 
of  cocaine  or  suprarenal  extract  will  sometimes  contract  the  tumors  so 
that  they  can  be  reduced  without  general  anaesthesia. 

Accidents  and  Complications  following  Opeeations  for  H.^m- 
OERHOiDS. — Certain  accidents  and  complications  are  liable  to  follow  all 


HEMORRHOIDS— PILES  661 

operative  methods  for  hgemorrhoids.  They  are  more  frequent  in  some 
than  in  others,  but  practically  of  the  same  nature  in  all. 

Pain. — There  is  a  wide  variation  in  the  statements  of  different 
authors  regarding  the  pain  following  one  operation  or  another.  Ailing- 
ham^  Mathews,  Goodsall,  and  Bacon  state  that  after  the  ligature  the 
pain  is  very  slight  and  of  short  duration.  A  careful  inquiry  from 
the  internes  in  ten  large  hospitals,  instituted  some  five  years  ago,  es- 
tablished the  fact  that,  in  these  institutions  at  least,  patients  having 
undergone  operation  by  ligature  require  four  times  as  much  morphine 
as  those  operated  upon  by  the  clamp  and  cautery  or  the  Wliitehead 
operation.  There  seems  to  be  little  difference  in  this  respect  whether  the 
Allingham,  Bodenhamer,  or  Mathews  operation  is  employed.  Where  a 
deep  groove  is  cut  entirely  through  the  skin  and  muco-cutaneous  tissue, 
and  the  ligature  fits  accurately  into  it,  the  pain  is  less  than  where  these 
tissues  are  tied  with  the  pile;  unless  this  is  done,  the  operation  can 
not  be  said  to  have  been  properly  performed.  Notwithstanding  this 
precaution,  the  ligature  operation  always  occasions  a  great  deal  of  pain. 
The  clamp-and-cautery  method,  if  properly  done,  is  followed  by  con- 
siderably less  pain  than  the  ligature;  nevertheless,  there  are  cases  in 
which  it  produces  great  suffering,  and  it  is  sometimes  difficult  to 
determine  the  cause  thereof.  It  is  not  due  in  either  operation  to 
spasm  of  the  sphincter,  otherwise  restretching  of  this  muscle  would 
relieve  it,  and  it  does  not  do  so.  The  most  probable  explanation  of 
the  excessive  pain  which  some  patients  suffer  after  either  the  ligature 
or  the  clamp  and  cautery  lies  in  the  supposition  that  some  nerve-end 
is  caught  in  the  ligature  or  in  the  charred  surface.  The  personal  ele- 
ment, however,  must  be  reckoned  with  in  every  operation;  some  patients 
will  bear  without  complaining  what  others  describe  as  intolerable 
agony.  As  a  rule,  there  is  not  a  great  deal  of  pain  following  the  clamp- 
and-cautery  operation  after  the  first  twenty-four  hours,  and  if  the 
parts  are  dressed  with  ansesthesin  there  will  be  very  little  even  during 
this  period.  It  is  a  rare  thing  for  cases  operated  on  by  this  method 
to  require  more  than  one  hypodermic  injection  of  morphine. 

Following  the  method  of  excision  the  pain  is  very  great  for  eight 
or  ten  hours;  after  this  it  subsides,  and,  unless  there  is  some  other 
complication,  it  practically  ceases.  Morphine  is  the  best  remedy  to 
control  it  after  all  operations,  but  occasionally  large  doses  of  bromide 
of  soda  will  act  more  satisfactorily  in  cases  of  extreme  nervous  irrita- 
bility. The  smarting  pain  which  follows  a  movement  of  the  bowels 
in  either  operation  may  be  relieved  by  the  application  of  pure  iodoform, 
a  10-per-cent  ichthyol  ointment,  or  the  insufilation  of  orthoform  just 
before  the  stool. 

Dysuria. — Strangury  and  dysuria  are  almost  inseparable  from  the 


602  THE  ANUS,  RECTUM,   AND   PELVIC   COLON 

ligature  operation.  Tlie  writer  does  not  remember  a  single  ease  where 
this  method  was  used  in  which  it  was  not  necessary  to  catheterize 
the  patient  for  some  days  or  even  weeks  afterward.  This  is  some< 
times  necessary  after  the  clamp-and-cautery  and  excision  methods,  but 
not  nearly  as  frequently  so  as  after  the  ligature.  The  closer  the  rec- 
tum is  packed  the  more  likely  catheterization  will  have  to  be  employed. 
One  should  not  be  in  too  great  a  hurry,  however,  in  drawing  off  the 
urine,  for  sometimes  hot  applications  over  the  pubis  and  allowing  the 
patient  to  stand  on  his  feet  will  enable  us  to  obtain  voluntary  urina- 
tion. Unless  there  is  great  distress  it  is  best  to  allow  the  patient  to 
go  for  eight,  twelve,  or  even  sixteen  hours  before  resorting  to  the 
catheter.  Either  a  sterilized,  soft-rubber,  or  Van  Buren  silver  instru- 
ment should  be  used  for  this  purpose;  woven  instruments  with  sharp 
ends  are  very  objectionable.  The  urethra  should  be  washed  out  with 
boric-acid  solutions  before  any  instrument  is  introduced. 

Period  of  Confinement. — According  to  the  most  enthusiastic  advo- 
cates of  the  ligature  operation,  the  patient  must  be  confined  to  his 
room  for  two  or  three  weeks,  and  be  kept  quiet  in  bed  from  seven 
to  fourteen  days,  until  the  ligatures  come  away;  the  period  at  which 
this  happens  is  very  indefinite;  it  varies  from  five  to  thirty-five  days, 
as  the  writer  saw  in  one  case  in  1899.  It  is  therefore  impossible  to 
tell  with  any  degree  of  certainty  how  long  a  patient  will  be  confined 
by  this  method.  Some  surgeons  allow  their  patients  to  get  up  and 
go  about  before  the  ligatures  come  away,  but  this  is  dangerous  and 
should  not  be  done. 

After  the  clamp-and-cautery  operation  the  patient  is  only  con- 
fined to  his  bed  for  the  first  three  days,  after  which  time  he  is  allowed 
to  walk  around  the  room,  and  generally  returns  to  his  business  in 
seven  days  from  the  time  of  the  operation,  although  the  parts  are 
rarely  completely  healed  under  three  weeks.  The  time  consumed  in 
healing  over  the  granulating  surfaces  is  on  an  average  about  one  week 
less  by  this  method  than  by  the  ligature. 

Following  the  methods  of  excision  the  patient  must  be  confined  to 
bed  for  seven  or  eight  days.  If  primary  union  has  then  taken  place, 
the  parts  will  be  completely  united  and  practically  well,  but  if  failure 
in  union  has  occurred  at  any  point  in  the  circumference,  the  patient 
should  be  kept  quiet  until  the  granulated  spot  has  healed.  In  this 
respect,  therefore,  the  clamp  and  cautery  has  the  advantage  over  all 
other  operations,  in  that  there  is  no  necessity  for  the  patient  to  lie 
in  bed  after  the  first  seventy-two  hours. 

Secondary  Hcemorrhage. — The  danger  of  secondary  haemorrhage  is 
greatly  exaggerated  by  quacks  and  charlatans  who  do  not  operate  for 
haemorrhoids.     If   a   blood-vessel   is   thoroughly   tied    off,   crushed,   or 


HEMORRHOIDS— PILES  663 

cauterized,  there  is  very  little  danger  of  hsemorrhage  from  it.  If  a 
ligature  should  slip  within  the  first  few  hours  after  operation,  bleeding 
may  occur,  but  such  an  accident  is  so  rare  that  one  need  hardly  con- 
sider it  as  a  serious  complication.  Thorough  packing  of  the  rectum 
with  gauze  will  check  it  in  any  case.  If  one  has  at  hand  a  conical 
sponge,  such  as  is  used  by  Allingham,  and  will  introduce  it  into  the 
ampulla  through  a  tube,  and  then  drag  down  upon  it  by  the  cord 
run  through  its  center,  the  bleeding  may  be  quickly  stopped.  The 
gauze,  however,  is  always  at  hand,  is  more  easily  sterilized,  and  more 
likely  to  produce  general  compression  than  the  sponge.  The  introduc- 
tion of  astringents,  other  than  cold  or  very  hot  water,  is  absolutely 
unnecessary,  and  is  injurious  in  these  cases;  perchloride  of  iron  not  only 
irritates  the  parts  but  it  forms  a  hard,  brittle  clot  which  may  break  off 
when  the  dressing  is  removed  and  thus  cause  the  bleeding  to  recur. 

Where  these  methods  do  not  check  the  haemorrhage  in  a  very  short 
time,  the  operator  should  not  hesitate  to  reansesthetize  the  patient, 
stretch  the  parts  open,  and  tie  the  bleeding  vessels.  In  the  very  many 
cases  operated  upon  by  the  clamp-and-cautery  method  the  writer  has 
seen  only  one  hemorrhage,  and  this  was  due  to  the  fact  that  he  allowed 
the  stump  to  slip  out  of  the  clamp  before  it  was  cauterized;  this  acci- 
dent occurred  through  not  running  down  the  screw  which  holds  the 
clamp  together,  and  since  that  time  this  little  precaution  has  never 
been  neglected.  In  this  case  the  crushing  by  the  clamp  controlled  the 
bleeding  for  the  time  being,  but  the  pulsation  of  the  artery  overcame 
this  obstruction  and  a  concealed  hsemorrhage  occurred  which  nearly 
cost  the  patient  his  life.  It  should  be  distinctly  stated  that  this  acci- 
dent was  due  to  an  error  of  the  operator  and  not  to  the  operation. 

In  the  excision  method  the  primary  bleeding  is  considerable,  but 
secondary  hsemorrhage  is  almost  unknown.  The  case  related  above, 
where  the  sutures  were  all  torn  loose  and  the  cuff  of  mucous  mem- 
brane turned  up  into  the  rectum  through  a  misapprehension  on  the 
part  of  the  house  surgeon,  can  not  be  charged  to  the  operation.  If 
the  operations  are  properly  done  there  is  practically  no  danger  what- 
ever from  secondary  hsemorrhage. 

Erysipelas,  Tetanus,  and  Infection. — Erysipelas  may  occur  in  any 
of  the  operations  for  haemorrhoids  owing  to  infection  by  streptococcus, 
but  it  is  a  most  unusual  occurrence.  It  is  less  likely  to  follow  the 
clamp  and  cautery  simply  because  the  hot  iron  not  only  kills  the  germs 
and  bacteria  about  the  parts  at  the  time,  but  it  also  seals  the  mouths 
of  the  blood-vessels  and  lymphatics  in  the  stump,  thus  preventing  infec- 
tion through  these  channels.  It  should  be  prevented  by  proper  anti- 
septic precautions,  but  if  it  does  develop,  Crede's  ointment  is  almost 
a  specific  for  it. 


664  THE   ANUS,  RECTUM,  AND   PELVIC   COLON 

Tetanus  has  frequently  followed  the  ligature  operation.  Almost 
every  fatal  termination  in  operations  for  haemorrhoids  has  been  due 
to  this  disease,  and  in  every  one  of  them  the  operation  has  been  by 
the  ligature  method.  "Whether  this  is  a  coincidence  or  is  due  to  the 
fact  that  the  absorbent  silk  ligature  attracts  and  retains  in  its  meshes 
small  particles  of  isecal  matter  containing  the  bacillus,  thus  keeping 
them  in  close  contact  with  the  parts,  can  not  be  determined.  As  a 
matter  of  fact,  however,  no  case  of  the  disease  has  yet  been  reported 
as  following  operations  by  the  clamp-and-cautery  or  excision  methods. 

The  treatment  for  this  condition  is  laid  down  in  works  on  general 
surgery.  Eecently  some  cases  have  recovered  under  serum  therapy,  but, 
so  far  as  the  writer  knows,  no  case  developing  from  a  rectal  operation 
has  ever  been  cured. 

Abscess  and  Fistula. — These  conditions  have  been  kno-^Ti  to  follow 
operations  by  the  ligature,  by  the  clamp  and  cautery,  and  by  the  excision 
methods;  they  do  not  result  from  the  operations  themselves,  but  from 
traumatism  produced  by  stretching  the  sphincter.  The  operations  are 
usually  done  in  non-suppurating  cases,  and,  the  sphincter  being  thor- 
oughly stretched,  there  is  no  reason  why  the  complete  drainage  thus  ob- 
tained should  not  prevent  any  burrowing  and  abscess  formation  from 
the  wound  in  the  rectum. 

If,  however,  some  small  perirectal  blood-vessel  should  be  ruptured 
and  a  hsematoma  formed  in  the  cellular  tissue,  this  may  necrose  or  be- 
come infected  and  cause  perirectal  abscess.  The  writer  has  opened 
three  abscesses  of  this  kind,  and  evacuated  quantities  of  sero-pus  and 
broken-down  clots,  which  appear  to  prove  that  they  originated  in  peri- 
rectal hemorrhages.  Two  of  these  abscesses  followed  the  ligature 
method,  and  one  the  clamp  and  cautery.  The  only  treatment  in  these 
cases  is  to  open  and  drain  as  soon  as  the  perirectal  swelling  is  dis- 
covered. 

After  the  methods  of  excision  small  stitch-hole  or  burrowing  ab- 
scesses may  occur,  but  they  should  not  attain  any  great  size.  As  soon 
as  the  evidences  of  such  appear,  the  surgeon  should  cut  the  stitches  at 
this  point  at  once,  and  thus  drain  it.  The  writer  has  done  this  in  two 
instances,  and  in  each  case  has  obtained  primary  union,  with  the  excep- 
tion of  the  small  area  which  was  opened  to  drain  the  abscess.  It  is  a 
complication  above  all  others  which  makes  careful  watching  and  daily 
examination  of  the  patients  having  undergone  operations  for  haemor- 
rhoids important.  The  first  quickening  of  the  pulse  or  rise  of  tem- 
perature after  the  twenty-four  hours  following  operations  should  excite 
suspicion  and  suggest  immediate  and  thorough  examination  of  the  parts. 

Stricture. — Stricture  has  been  frequently  spoken  of  as  the  result 
of  all  operations  for  hasmorrhoids.     Allingham  states  that  following 


HiEMORRHOIDS— PILES  665 

the  ligature  operation  it  is  due  to  tying  off  of  too  large  masses  of  mucous 
membrane  in  one  ligature,  and  shows  in  his  drawings  that  by  this  method 
a  large  raw  surface  is  left  partially  surrounding  the  rectum.  He  does 
not  think,  however,  that  the  stricture  is  due  to  cicatricial  contraction 
from  the  large  granulating  area,  but  that  it  is  caused  by  the  massing 
together  of  folds  of  mucous  membrane  which  causes  adhesions  that  do 
not  readily  give  way,  an  explanation  that  is  very  plausible.  He  also 
attributes  these  strictures  to  patients  getting  up  before  the  wounds  are 
healed,  and  in  order  to  avoid  them,  advises  the  daily  passage  of  the 
finger  or  a  moderate-sized  bougie  into  the  rectum  until  the  wound  is 
completely  healed  over. 

Following  the  clamp-and-cautery  operation,  stricture  is  certainly 
one  of  the  rarest  complications.  If  the  htemorrhoid  is  caught  in  the 
line  of  the  long  axis  of  the  gut  it  will  never  occur,  but  if  it  is  caught 
transversely  so  that  the  cicatrix  runs  around  the  lower  end  of  the  rec- 
tum, contraction  may  result.  Smith  and  Kelsey,  after  operating  upon 
thousands  of  cases  by  this  method,  have  failed  to  see  a  single  case  of 
stricture  following  it.     The  author  has  seen  only  one. 

After  the  Whitehead  operation,  however,  stricture  is  likly  to  occur 
even  when  primary  union  is  obtained.  There  must  be  a  circular  cicatrix 
at  the  line  of  union,  and  if  there  is  a  deposit  of  fibrous  tissue  beneath 
this,  contraction  will  take  place.  This  may  be  caused  by  too  deep  dis- 
section or  not  loosening  the  mucous  membrane  high  enough  up,  so  that 
when  it  is  drawn  down  it  produces  a  sort  of  roll  or  tuck  in  the  walls  of 
the  gut,  which  narrows  the  caliber,  and  becoming  matted  together  by 
inflammatory  processes  forms  a  true  stricture. 

A  large  number  of  strictures  of  the  anus  are  seen  to-day  as  the  result 
of  this  operation.  "While  the  writer  has  only  seen  2  in  over  200  opera- 
tions in  his  own  practice,  he  has  seen  T  in  cases  where  the  Whitehead 
operation  was  said  to  have  been  done  by  other  surgeons.  This  compli- 
cation is  much  less  likely  to  follow  the  ligature  or  clamp  and  cautery 
than  the  Whitehead  operation. 

Ulceration  and  Fissure. — Protracted  ulceration  or  chronic  fissures 
have  been  known  to  follow  the  Wliitehead,  clamp-and-cautery,  and  liga- 
ture operations.  '\Miile  Mathews  is  honest  when  he  says  that  he  has 
never  seen  an  unfortunate  result  follow  the  ligature  method,  the  author 
has  seen  1  patient  upon  whom  this  eminent  surgeon  operated,  and  who 
is  stni  suffering,  after  nearly  three  years,  with  chronic  ulceration  at 
the  posterior  commissure  of  the  rectum,  together  with  a  slight  contrac- 
tion in  the  caliber  of  the  gut.  In  10  patients  under  the  writer's  care, 
the  ulceration  following  this  operation  has  persisted  from  three  months 
to  two  vears;  such  a  result  is  rare  in  comparison  with  the  number  oper- 
ated on,  but  it  occurs  more  frequently  after  the  ligature  than  after  the 


666  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

clamp-and-cauterv  or  excision  methods.  The  constitutional  condition 
of  the  patient  will  account  for  this  in  the  majorit}'  of  cases,  and  in  those 
eases  in  which  it  has  occurred,  it  might  have  done  so  had  an}'  other 
method  been  used. 

In  summing  up  the  accidents  and  complications  following  operations 
for  ha?morrhoids,  it  is  fair  to  say  that  untoward  results  occur  occasionally 
in  all  of  them,  but  they  are  less  frequent  and  less  severe  after  the  clamp 
and  cautery  than  after  any  other  method. 

Becapitulatian. — After  this  prolonged  discussion  one  may  be  some- 
what confused  as  to  the  method  to  be  used  in  an  individual  case.  Ex- 
perience only  can  teach  this.  In  the  early  stages  of  the  disease  the 
palliative  treatment  will  always  relieve,  frequently  results  in  permanent 
cure,  and  ought  to  be  given  a  trial.  In  uncomplicated  varicose  internal 
haemorrhoids,  with  relaxed  sphincters,  the  injection  metJiod  is  compara- 
tively safe,  and  its  results  are  very  satisfactor}^  in  the  majority  of  in- 
stances. In  strangulated,  mixed,  and  ulcerating  piles,  or  those  with 
considerable  connective  tissue  in  their  substance,  the  damp  and  cautery 
is  by  far  the  best  method.  In  hemorrhagic  cases,  or  those  with  atherom- 
atous arteries,  the  ligature  is  probably  the  safest  method.  In  cases 
with  only  one  or  two  marked  haemorrhoids,  partial  excision  by  the  aid  of 
Earle's  clamp  appears  to  be  an  ideal  operation.  AMiere  there  is  a  general 
varicosity  of  the  lower  end  of  the  rectum,  with  prolapse  of  the  mucous 
membrane,  excision  with  immediate  suture  will  give  the  best  results.  On 
account  of  its  applicability  to  all  varieties,  the  ease  and  celerity  with 
which  it  can  be  applied,  and  its  uniformly  good  results,  the  clamp  and 
cautery  easily  stands  first  among  the  operations  for  haemorrhoids. 


CHAPTEE    XVII 
PROLAPSE   OF   THE  RECTUM,    PROCIDENTIA    INTESTINI  RECTI 

Peolapsus  and  procidentia,  both  of  Latin  derivation,  are  identical  in 
their  meaning,  and  signify  a  falling  down.  Some  authorities  have  at- 
tempted to  establish  a  distinction  between  the  two,  limiting  the  term 
prolapsus  to  a  descent  of  mucous  membrane,  and  procidentia  to  those 
conditions  in  which  all  the  coats  of  the  gut  come  down.  Allingham 
(Diseases  of  the  Eectum,  1896,  p.  209)  goes  further  than  this,  and  says: 
"  By  prolapse  is  meant  a  protrusion  outside  the  anus  of  a  portion  or 
portions  of  the  mucous  membrane,  not  in  its  entire  circumference  and 
unaffected  by  piles.  The  term  j^rocidentia  must  be  confined  to  a  descent 
of  the  whole  circumference  of  the  rectum."  This  limitation  of  the  term 
prolapsus  is  entirely  too  restricted,  and  there  is  no  authority  for  it  in 
etymology  or  literature.  Cases  occur  in  which  the  mucous  membrane 
prolapses  in  its  entire  circumference  with  one  or  two  haemorrhoids  at 
different  points,  and  yet  these  would  be  excluded  under  the  definition  of 
this  gifted  surgeon.  Prolapsus  has  been  applied  for  centuries  to  all 
degrees  of  falling  of  the  rectum,  and  it  is  too  late  to  put  such  a  restriction 
on  its  use.  It  is  the  generic  term,  and  applicable  to  all  types  of  the  con- 
dition, and  will  be  so  used  in  this  work.  Procidentia,  however,  has  not 
been  so  generally  employed,  and  is  practically  always  applied  to  those 
cases  in  which  all  the  coats  of  the  bowel  descend.  It  will  be  so  used  here. 
It  is  not  so  important  that  the  prolapse  does  or  does  not  involve  the 
entire  circumference  of  the  gut,  as  it  is  that  it  involves  only  a  part  or  the 
whole  of  its  thickness.  Prolapsus  is  divided  into  incomplete  or  partial 
prolapse,  in  which  the  mucous  membrane  alone  descends;  and  complete 
prolapse  or  procidentia  recti,  in  which  all  the  coats  of  the  bowel — the 
mucous,  submucous,  muscular,  and  even  the  peritoneal — take  part.  Ac- 
cording to  this  division  the  term  prolapse  may  signify  any  form  or  degree 
of  descent,  while  procidentia  applies  only  to  the  different  degrees  of  com- 
plete prolapsus. 

Incomplete  Prolapse. — This  variety,  called  also  partial  prolapse  by 
Cripps  {pp.  cit.,  p.  120),  consists  in  a  sagging  down,  or  protrusion  from 

667 


668 


THE   ANUS,   RECTUM,   AND   PELVIC   COLON 


the  anus^  of  the  mucous  membrane  of  the  rectum  (Fig.  221).  It  is  an 
exaggeration  of  the  normal  physiological  eversion  which  occurs  at  every 
stool.  In  health  the  loose  fibrous  and  elastic  tissues  allow  a  certain 
amoimt  of  protrusion  of  the  membrane  which  facilitates  the  ejection  of 
the  faecal  mass,  and  when  the  act  of  defecation  is  completed  retract  it 
by  their  elasticity.  In  pathological  conditions  these  tissues  become 
stretched  and  permanently  elongated;  they  lose  their  elasticity,  and  thus 

not  only  allow  the 
mucous  membrane  to 
extrude  to  an  abnor- 
mal degree,  but  fail 
to  draw  it  up  again. 

This  is  the  most 
frequent  form  of 
prolapse,  and  occurs 
constantly  in  acute 
proctitis  with  oede- 
ma, in  haemorrhoids, 
and  in  superficial 
neoplasms  of  the 
rectum. 

Etiology. — Age. — 
The  disease  is  found 
most  frequently  in  young  children  and  in  the  very  old.  In  adults  it 
is  not  at  all  frequent,  but  occasionally  occurs  in  women  who  have  suf- 
fered from  complete  rupture  of  the  perinseum  or  after  prolonged,  ex- 
hausting diseases.  Those  states  in  which  there  is  relaxation  of  the 
sphincter  muscles  and  reduction  of  the  fatty  cushions  which  surround 
the  lower  end  of  the  rectum  and  anus  are  all  predisposing  causes. 
The  exciting  causes  are: 

1.  Whatever  separates  the  mucous  from  the  muscular  wall  of  the 
gut,  such  as  oedema  or  inflammatory  effusion  into  the  submucosa.  Mol- 
liere  (op.  cit.,  p.  199)  proved  this,  and  produced  the  disease  artificially 
by  introducing  a  blow-pipe  beneath  the  mucous  membrane  and  insuf- 
flating air  into  the  submucous  tissue,  thus  separating  the  mucous  from 
the  muscular  wall  of  the  gut,  and  causing  the  former  to  extrude  from 
the  anus. 

2.  Those  conditions  which  produce  weakness  or  dilatation  of  the 
sphintcer  muscles,  such  as  exhausting  diseases,  paralysis,  incisions,  over- 
distention,  sodomy,  and  traumatic  injuries  to  the  sacral  plexus  of  nerves. 

3.  Whatever  mechanically  drags  down  upon  the  mucous  membrane 
— i.  e.,  haemorrhoids,  tumors  attached  to  the  membrane,  polyps,  and 
hard  costive  stools. 


Fig.  221. — Incomplete  Prolapse  of  the  Eectcm. 


PROLAPSE  OF  THE  RECTUM  669 

4.  All  those  diseases  and  conditions  which  produce  increased  peri- 
stalsis and  straining  efforts  at  stool,  such  as  pinworms,  foreign  bodies 
in  the  rectum,  ulcerations,  proctitis,  urethritis,  stricture  of  the  urethra, 
cystitis,  stone,  phimosis,  and  enlarged  prostate. 

5.  Prolonged  sitting  and  efforts  at  defecation.  The  pernicious  habit 
of  seating  little  children  on  vessels  and  compelling  them  to  sit  there 
until  the  bowels  move  is  one  of  the  most  frequent  causes.  Old  men  of 
leisure,  who  are  accustomed  to  take  their  pipe  and  morning  paper  to  the 
toilet  with  them,  often  suffer  from  this  form  of  the  disease. 

6.  Diarrhoea,  especially  the  summer  diarrhoea  of  children,  dysentery, 
and  cholera  morbus,  with  excessive  vomiting,  may  all  bring  about  this 
condition. 

Symptoms. — The  symptoms  of  incomplete  prolapse  are  at  first  very 
meager.  The  condition  never  comes  on  suddenly,  and  in  the  beginning 
is  not  accompanied  by  pain,  itching,  or  discharge  of  any  kind.  There  is 
simply  an  exaggeration  in  the  normal  protrusion  of  the  mucous  mem- 
brane at  the  time  of  stool.  This  gradually  increases  until  it  becomes 
perceptible  and  annoying.  The  extent  of  the  incomplete  prolapse  is 
limited  by  the  distensibility  of  the  fibrous  attachment  between  the 
mucous  membrane  and  the  muscular  walls.  One  to  2^  inches  may  be  said 
to  represent  the  possible  extent  of  such  a  prolapse. 

At  first  the  prolapse  is  spontaneously  reduced  or  recedes  under  gentle 
pressure,  but  as  it  increases  and  the  membrane  grows  thicker  through 
inflammatory  changes,  it  is  grasped  more  or  less  firmly  by  the  sphincter 
muscle,  and  reduction  becomes  more  difficult.  In  this  type  of  the  dis- 
ease, however,  strangulation  of  the  prolapsed  gut  and  sloughing,  such 
as  takes  place  in  the  complete  variety,  are  rarely  seen. 

The  color  of  the  prolapse  is  at  first  like  that  of  the  normal  mucous 
membrane.  It  gradually  assumes  a  bright-red  or  scarlet  as  the  irrita- 
tion from  sliding  up  and  down  increases,  and  when  constricted  by  the 
sphincter  it  may  assume  a  dark-purplish  or  gangrenous  hue. 

The  prolapse  may  involve  the  entire  circumference  of  the  anus  or 
only  a  part  of  it.  When  it  involves  the  entire  circumference,  it  will  be 
composed  of  longitudinal  folds  which  radiate  from  the  center  to  the 
circumference.  This  direction  of  the  folds  or  sulci  distinguishes  the 
incomplete  from  the  complete  form  of  prolapsus.  The  surface  of  the 
protrusion  may  be  smooth  or  lobulated  according  to  the  inflammatory,  . 
hsemorrhoidal,  or  neoplastic  conditions  complicating  it.  Excessive 
hgemorrhoidal  disease  is  always  associated  with  more  or  less  prolapse  of 
the  mucous  membrane,  and  in  these  cases  we  observe  the  three  or  four 
cardinal  tumors  with  a  sagging  down  of  the  mucous  membrane  of  the 
rectum  between  them.  Pain,  haemorrhage,  ulceration,  and  suppuration 
occur  later  in  the  disease  as  the  result  of  friction  due  to  the  slipping  up 


670  THE  AXUS,   RECTCM,   AND   PELVIC   COLON 

and  dowTi  of  the  prolapsing  membrane,  to  constriction  by  the  sphincter 
muscle,  or  irritation  by  the  passage  of  hard  faecal  masses.  These  symp- 
toms, however,  are  secondary  complications  of  the  disease  and  not  a 
part  of  it. 

Treatment. — The  treatment  of  this  type  of  prolapse  is  very  smiple. 
The  removal  of  the  cause,  where  it  is  apparent,  is  always  the  first  step. 
Haemorrhoids,  polypi,  and  other  neoplasms  should  be  excised,  and  the 
operations  accomplishing  this  will  ordinarily  result  in  the  cure  of  in- 
complete prolapsus. 

In  children  and  old  people  the  habit  of  prolonged  sitting  at  stool 
should  be  discontinued.  A  cold  enema  should  be  administered  just  be- 
fore going  to  the  toilet  in  order  that  defecation  may  be  accomplished 
promptly  and  with  ease.  Such  reflex  causes  as  phimosis,  stone,  urethral 
stricture,  etc.,  should  be  eliminated  before  attempting  any  operative 
treatment  for  this  condition.  In  children  a  very  large  majority  of  these 
cases  can  be  cured  without  any  surgical  operation.  Active  tonic  treat- 
ment, careful  attention  to  the  movement  of  the  bowels,  cold  applications 
and  electricity  to  the  anus,  and  plenty  of  fresh  air  will  generally  accom- 
plish a  cure. 

In  elderly  people,  however,  the  organic  changes  in  the  fibrous  attach- 
ment of  the  mucous  membrane  are  not  so  easily  overcome,  and  operation 
is  very  frequently  called  for. 

The  operative  methods  employed  in  this  type  of  disease  consist  in 
cauterization  of  the  mucous  membrane,  and  in  partial  or  complete  ex- 
cision. Allingham  advises  cauterizing  the  entire  surface  of  the  prolapse 
with  fuming  nitric  acid^  and  believes  that  this  will  set  up  an  inflam- 
matory condition  of  the  submucosa  which  will  shorten  the  fibrous 
connections  between  it  and  the  muscular  wall,  thus  overcoming  the 
prolapse.  The  method  of  Van  Buren  is  based  upon  a  similar  view, 
and  consists  in  cauterizing  the  prolapse  with  the  actual  cautery, 
heated  to  a  red  heat,  in  lines  about  ^  inch  apart  throughout  its  en- 
tire extent. 

It  is  difficult  to  understand  how  either  one  of  these  methods  acts 
through  producing  a  submucous  inflammatory  condition,  for  whatever 
increases  the  separation  between  the  mucous  membrane  and  the  muscular 
wall  tends  to  produce  prolapsus.  It  does  not  seem  to  the  writer,  there- 
fore, that  the  method  of  repair  follows  the  course  laid  down  by  these 
eminent  authors;  the  results  are  more  probably  due  to  the  spasmodic 
contraction  of  the  sphincter  and  the  prolonged  constipation  produced 
by  these  cauterizations,  together  with  the  actual  narrowing  of  the  lower 
end  of  the  intestinal  canal.  If  the  prolapse  is  overcome  by  the  production 
of  submucous  inflammation  between  the  mucous  membrane  of  the  rectal 
wall,  the  same  can  be  set  up  by  h3^odermic  injections  of  chemical  sub- 


PROLAPSE  OP  THE  RECTUM  671 

stances  into  this  space  without  the  necessity  of  ulceration  and  inflam- 
mation in  the  mucous  membrane  itself.  Occasionally  this  condition  has 
been  cured  by  such  methods,  and  the  author  would  certainly  advise  their 
application  before  any  attempts  at  cauterization  by  the  Allingham  or 
Van  Buren  methods. 

The  injection  treatment  of  incomplete  prolapse  consists  in  the  intro- 
duction of  3  to  5  minims  of  modified  Shuford's  solution  into  the  sub- 
mucous tissue  at  several  points  around  the  circumference  of  the  anus. 
After  this  injection  has  been  completed,  a  rubber  drainage-tube  should 
be  introduced  into  the  rectum,  and  the  rectal  ampulla  packed  thoroughly 
with  gauze  so  as  to  hold  the  gut  in  position.  The  drainage-tube  will 
serve  for  the  escape  of  gases,  and  the  bowels  should  be  confined  for 
seven  to  ten  days.  A  firm  compress  should  be  kept  over  the  anus  at  first 
in  order  to  prevent  the  mucous  membrane  from  coming  doAvn,  and  the 
patient  should  be  kept  under  the  influence  of  opiates  sufiiciently  to 
control  peristalsis  and  efforts  to  expel  the  rectal  packing.  If  care- 
fully performed  with  proper  antiseptic  precautions,  there  is  no  dan- 
ger of  suppuration  or  sloughing  in  this  method,  and  the  percentage 
of  cures  is  fully  equal  to  that  by  the  cauterizing  methods  mentioned 
above. 

The  radical  and  certain  cure  of  these  conditions,  however,  consists 
in  partial  or  complete  excision  of  the  prolapsing  mucous  membrane. 
Partial  excision  consists  in  taking  out  elliptical  portions  of  the  mu- 
cous membrane  at  three  or  four  points  around  the  circumference  of 
the  prolapse.  This  may  be  done  in  two  ways:  first,  by  excising  the 
mucous  membrane  with  scissors  and  suturing  the  edges  of  the  wound 
together;  secondly,  by  grasping  strips  of  the  membrane  in  the  hEemor- 
rhoidal  clamp,  and  removing  them  just  as  one  would  a  hsemorrhoidal 
tumor.  The  latter  method  is  far  simpler,  and  accomplishes  just  as  good 
results,  for  in  the  large  majority  of  cases  the  sutured  wounds  do  not 
heal  by  primary  union,  and  in  the  end  we  have  to  deal  with  a  granu- 
lating wound  such  as  follows  the  operation  by  the  clamp  and  cautery. 
In  applving  the  clamp  and  cautery  to  this  condition,  one  should  always 
observe  the  same  rules  as  are  laid  down  in  the  operation  for  haemorrhoids, 
viz.,  that  the  muco-cutaneous  tissue  should  never  be  embraced  in  the 
part  cauterized,  and  the  long  axis  of  the  portion  removed  should  be 
parallel  with  that  of  the  rectum.  This  method,  employed  entirely  by 
Henry  Smith,  gives  uniformly  good  results,  and  can  be  performed  by 
any  surgeon. 

The  method  of  complete  excision  of  the  prolapsing  mucous  membrane 
consists  in  nothing  more  nor  less  than  a  Whitehead  operation.  This 
has  already  been  described  in  the  chapter  upon  hemorrhoids.  The  only 
precautions  necessary  to  be  repeated  here  are,  first,  the  necessity  of  care- 


672 


THE  ANUS,  EECTUM,   AND   PELVIC  COLON 


fill  antiseptic  preparation  and  technique,  of  keeping  the  incision  entirely 
witliin  the  mucous  membrane,  and  the  importance  of  careful  adjust- 
ment of  the  edges  of  the  wound  so  as  to  avoid  tension  and  tearing 
through  of  the  sutures. 

TJie  same  objections  may  be  urged  against  the  operation  in  prolapsus 
as  have  been  urged  under  the  subject  of  ha^norrhoids.  The  non-operative 
and  the  clamp-and-cautery  methods  laid  down  above  will  prove  the  most 

satisfactory  treatment 
in  a  large  majority  of 
the  cases.  In  this 
minor  degree  of  pro- 
lapsus the  writer  has 
not  found  any  advan- 
tage from  strapping 
the  buttocks  together 
or  requiring  the  pa- 
tient to  lie  in  the  re- 
cumbent posture  when 
his  bowels  move.  The 
mucous  membrane  will 
prolapse  in  this  posi- 
tion just  as  much  as 
if  the  patient  sits  upon 
the  commode. 

The  ligature  opera- 
tion in  the  treatment 
of  this  condition,  al- 
though it  is  advised  by 
Mathews,  Allingham, 
and  other  operators,  is 
not  so  satisfactory  as 
the  clamp  and  cautery, 
although  it  will  cure 
tliose  cases  which  are 
due  to  hypertrophied 
haemorrhoids. 

Complete    Peo- 

LAPSE,     PeOCIDEXTIA 

IxTESTixi    Recti. — 
There  are  three  degrees 
of  complete  prolapse  of  the  rectum,  all  of  which  involve  a  descent  of 
the  rectum  in  all  its  coats  to  a  greater  or  less  extent.     They  are  dis- 
tinguished as  follows: 


Fig.  223.— Complete  Procidentia  Recti— Second  Degree. 


PROLAPSE  OF  THE  RECTUM 


67? 


First  Degree:  In  this  the  prolapse  hegins  at  the  margin  of  the  anus, 
and  its  external  surface  is  continuous  with  the  skin  surrounding  this 
aperture  (Fig.  232). 

Second  Degree:  The  prolapse  hegins  at  a  point  more  or  less  above  the 
anus,  and,  descending  through  that  portion  of  the  gut  which  remains  in 
position,  protrudes  through  the  anal  orifice  (Fig.  223). 

Third  Degree:  The  prolapse  hegins  high  up  in  the  rectum,  or  sigmoid 
flexure  and  extends  down  into  the  ampulla  of  the  rectum,  hut  does  not 
protrude  through  the 
anal  orifice  (Fig.  224). 

These  three  de- 
grees vary  consider- 
ably in  their  symp- 
toms and  treatment, 
and  therefore  merit 
separate  considera- 
tion. 

The  First  Degree. 
— This  variety  of  pro- 
cidentia is  brought 
about  by  the  same 
causes  as  incomplete 
prolapsus;  it  is  fre- 
quently a  sequence  of 
the  latter.  Partial 
prolapse  can  only  ex- 
tend to  a  limited  de- 
gree before  the  fibrous 
attachment  of  the  mu- 
cous membrane  to  the 
muscular  wall  begins 
to  drag  forcibly  upon 

the   latter,    and    event-         Fig.  224.— Complete  Peocidexntia  Kecti— Third  Degree. 

ually  carries  it  down- 
ward, thus  bringing  about  a  complete  prolapse  of  the  first  degree.  This 
form,  however,  rarely  occurs  in  connection  with  hasmorrhoids,  owing  to 
the  fact  that  these  growths  are  situated  at  a  very  short  distance  above 
the  muco-cutaneous  margin  and  only  drag  the  mucous  membrane  down 
to  that  limited  extent  that  will  be  permitted  by  the  stretching  of  the 
elastic  bands  in  the  submucosa.  When  the  attachment  of  the  neoplasm 
which  causes  a  prolapse  reaches  the  lowest  point  of  the  latter,  it  then 
drags  upon  the  external  attachment  around  the  margin  of  the  anus  as 
well  as  upon  the  mucous  membrane  of  the  gut  above,  and  consequently 
43 


674: 


THE  AXUS,  RECTUM,  AND   PEL^^C  COLOX 


the  prolapse  can  not  proceed  auv  farther.  Therefore,  as  the  hsemor- 
rhoids  are  attached  low  down  in  the  rectum,  prolapse  from  this  cause 
can  never  be  excessive.  When,  however,  the  condition  is  due  to  polypi 
or  neoplasms  higher  up  in  the  rectum,  the  organ  may  be  dragged  out- 
side of  the  rectum  to  the  extent  of  the  height  of  their  attachment. 

The  distinguishing  feature  of  this  degree  of  prolapse  consists  in  the 
fact  that  its  external  surface  is  continuous  with  the  cutaneous  surface 
surrounding  the  anus.    There  is  no  sulcus  between  the  prolapse  and  the 


Fig.  225. — Complete  Prolap?e  of  the  Kectum,  showing  Circulab  AEKAXGZiLEXT  or 

THE    ElG.E. 


anal  margin.  The  mucous  folds  which  run  up  and  do-mi  in  the  incom- 
plete variety  change  to  a  circtilar  direction  in  the  complete  tyjaes,  and 
surround  the  prolapse  in  irregular,  crescentic  folds  (Fig.  225). 

The  condition  may  come  on  gradually,  or  in  rare  instances  it  may 
be  suddenly  produced  by  crushing  accidents  or  excessive  straining  to 
lift  some  heavy  object.  "When  the  prolapse  is  first  protruded  its  color 
is  a  bright  red,  but  after  it  has  been  down  for  a  short  time  it  assumes 
a  dull  purplish  hue  due  to  venous  turgescence.  If  there  is  considerable 
obstruction  to  the  return  circulation,  it  may  become  tense,  swollen,  and 
shining,  thus  obliterating  the  circular  folds. 

In  the  beginning  the  prolapse  occurs  only  at  stool,  and  retires  spon- 
taneously.    Wliere  the  sphincters  are  relaxed  or  disabled,  however,  it 


PROLAPSE  OP  THE  RECTUM  675 

may  remain  down  all  the  time  unless  held  in  jjosition  by  compresses  or 
supporters  of  some  kind.  Occasionally  where  the  prolapse  is  produced 
suddenly,  it  may  be  constricted  by  the  sphincter  muscle,  and  its  reduc- 
tion may  be  quite  difficult.  In  the  early  stages  the  mucous  membrane 
is  not  altered  in  any  marked  degree,  but  after  repeated  prolapsing  and 
reduction  it  becomes  excoriated,  inflamed,  and  ulcerated  at  times.  There 
is  nearly  always  a  mucous  discharge,  and  occasionally  quite  serious 
hsemorrhages  occur  in  this  condition. 

Tlie  Second  Degree. — The  prolapse  begins  at  a  point  more  or  less 
removed  from  the  anus,  and  the  rectum  protrudes  through  this  orifice, 
thus  leaving  a  sulcus  or  space  between  the  protruding  gut  and  the 
anal  margin  into  which  can  be  introduced  a  probe,  or  sometimes  even 
the  finger,  to  the  height  at  which  the  prolapse  begins.  This  degree 
never  results  from  incomplete  23rolaj)se,  nor  from  haemorrhoids  or  tu- 
mors attached  within  the  first  inch  and  a  half  of  the  rectum.  It  may 
be  due  to  stricture,  ulceration,  or  neoplasm  of  the  gut  at  any  point 
abo.ve  an  inch  and  a  half.  "Whatever  causes  persistent  peristaltic  action, 
abdominal  straining,  and  prolonged  efforts  at  stool  may  bring  about  this 
type  of  jDrocidentia. 

It  may  occur  gradually,  or  it  may  be  produced  suddenly  by  some  vio- 
lent strain,  crushing  accident,  fall,  or  other  injury.  The  author  has 
seen  it  occur  during  ojjerations  for  haemorrhoids  after  the  sphincter  has 
been  dilated  and  the  patient,  only  partially  etherized,  begins  to  strain 
inordinately.  Under  these  circumstances,  however,  it  has  always  been 
very  temporary.  The  extent  of  prolapse  of  this  degree  is  limited  only 
by  the  length  of  the  colon  itself,  or  even  the  small  intestine.  Cases 
have  been  reported  in  which  the  whole  colon,  ileo-ca?cal  valve,  and  sev- 
eral feet  of  the  ileum  have  protruded  through  the  anus.  As  a  rule, 
however,  3  to  6  inches  is  the  average  amount  of  protrusion.  TMien  the 
prolapsus  does  not  exceed  3  or  4  inches  it  will  be  straight,  and  its  orifice 
will  point  in  a  line  parallel  with  the  long  axis  of  the  gut.  AYlien  it  ex- 
ceeds this  amount,  traction  upon  the  mesorectum  begins  to  draw  it 
backward,  and  thus  producing  a  curve  with  its  concavity  toward  the 
sacrum,  drags  the  orifice  in  this  line.  In  excessive  cases  of  procidentia 
the  mesosigmoid  and  mesocolon,  each  in  its  turn  dragging  upon  the 
prolapsed  organ,  twist  it  into  a  sort  of  corkscrew  shape,  sometimes 
making  as  many  as  two  or  three  circuits. 

Symptoms. — The  symptoms  of  procidentia  of  the  first  and  second 
degrees  are  practically  the  same.  In  children  the  mass  protrudes  only 
at  stool,  as  a  rule,  but  in  old  people,  where  there  is  atony  and  relaxation 
of  the  sphincters,  it  may  remain  down  all  the  time.  •  Constipation  is  the 
rule  in  young  and  old  alike  imtil  the  rectal  mucous  membrane  becomes 
excoriated  or  inflamed,  after  which  a  teasing,  irritating  diarrhoea  may 


676 


THE   ANUS,  RECTUM.  AND  PELVIC  COLON 


begin.  Discliarges  of  iiuiciis,  sometimes  tinged  Avith  blood,  are  nearly 
always  present.  Owing  to  the  relaxed  and  overstretched  condition  of  the 
sphincters,  the  loss  of  sensibility  in  the  mucous  membrane,  and  per- 
sistent peristalsis  kept  up  by  the  irritation  in  the  rectum,  a  mild  form 
of  incontinence  of  faeces  often  exists  in  these  cases.  Pain  is  not  a 
prominent  symptom  unless  there  is  ulceration  in  the  lower  portion  of  the 
rectum,  or  spasm  of  the  sphincter  constricting  the  prolapse. 

The  one  persistent  symptom  upon  which  the  diagnosis  rests,  consists 
in  a  protrusion  of  the  entire  thickness  of  the  gut  during  defecation. 
The  condition  can  only  be  confounded  with  luvmorrhoids  and  neoplasms 

of  the  rectum  which 
prolapse.  The  irregu- 
lar, lobulated  shape, 
the  varicose  condition 
of  the  vessels,  and  the 
fact  that  at  certain 
portions  of  the  cir- 
cumference of  the  rec- 
tum the  mucous  mem- 
brane remains  t?i  situ, 
serve  to  distinguish 
these  conditions  from 
procidentia. 

The  excoriation  and 
granulation  of  a  chron- 
ic procidentia  of  either 
the  first  or  second  de- 
gree sometimes  result 
in  a  hypertrophic,  nod- 
ular condition  which 
resembles  very  much 
epithelioma  of  the  rec- 
tum, and  can  only  be 
distinguished  from 
tliis  condition  by  mi- 
croscopic examination. 
As  will  be  seen  from  the  illustrations,  these  varieties  are  prone  to 
be  complicated  by  a  descent  of  the  recto-vesical  or  Douglas's  cul-de-sac, 
in  which  may  be  contained  loops  of  the  small  intestine,  thus  consti- 
tuting a  rectal  hernia  or  archocele. 

In  tlie  early  stages  of  this  condition  these  loops  are  contained  only 
in  tlie  anterior  portion  of  the  prolapse,  and  produce  a  smooth,  round 
prominence  it  this  portion  (Fig.  22G).     lUit  wliere  the  prolapse  lias  ex- 


■J.M. — Kectal  Hernia  vh  Akchocele. 


PROLAPSE  OF  THE  KECTUM  677 

tended  to  a  distance  of  5  or  6  inches  the  peritoneal  cul-de-sac  and  its 
hernial  contents  may  entirely  surround  the  gut,  with  the  exception  of 
the  narrow  portion  to  which  is  attached  the  mesentery.  Under  such 
circumstances  the  entire  circmnf  erence  of  the  prolapse  will  appear  much 
thickened,  soft,  and  pliable. 

The  diagnosis  of  this  condition  may  be  made  in  several  ways.  Per- 
cussion with  the  pleximeter  will  sometimes  give  a  tympanitic  note  en- 
abling one  to  say  that  there  is  air  between  the  two  layers  of  the  prolapse, 
but  this  does  not  positively  denote  the  existence  of  a  loop  of  intestine 
therein.  If,  when  the  prolapse  is  down,  the  patient  is  placed  in  the 
knee-chest  j)0sture  and  the  parts  manipulated,  the  gurgling  and  feel  of 
the  returning  gut  can  be  easily  distinguished,  just  as  in  the  case  of 
inguinal  hernia.  Occasionally  attachments  will  occur  between  the  small 
intestines  and  these  hernial  sacs,  making  it  impossible  to  reduce  the 
hernia  without  the  prolapse  being  carried  along  with  it;  in  such  cases 
strangulation  is  very  likely  to  occur.  Several  instances  have  been  re- 
ported in  which  the  rectum  has  ruptured  and  the  small  intestine  has 
burst  out  from  the  peritoneal  cavity  under  these  circumstances.  Strange 
to  say,  wherever  this  has  occurred,  the  prolapse  has  at  once  been  sjDonta- 
neously  reduced,  and  only  the  small  intestine  remained  protruding  from' 
the  anus.    Xo  satisfactory  explanation  of  this  fact  has  yet  been  given. 

Other  complications,  such  as  strangulation  and  gangrene,  with 
sloughing  of  the  prolapse,  have  been  noted  in  medical  literature,  but 
these  cases  chiefly  occurred  before  the  use  of  anaesthesia  became  so  gen- 
eral. 'With  it  prolapses  can  be  almost  invariably  reduced,  and  no  prac- 
titioner hesitates  to  employ  this  means  at  once. 

Third  Degree. — This  degree  of  procidentia  consists  in  a  falling  down 
or  intussusception  of  the  upper  jDortion  of  the  rectum  and  sigmoid  into 
the  lower  portion  or  rectal  ampulla.  It  differs  from  ordinary-  intussus- 
ception in  that  it  does  not  cause  strangury  or  complete  obstruction,  prob- 
ably on  account  of  the  wide  distensibility  of  the  rectal  ampulla:  and 
secondly,  the  peritoneal  coats  which  come  in  contact  with  each  other 
do  not  adhere  and  become  fixed  as  in  cases  of  ty]3ical  intussusception  of 
the  bowel  higher  up.  In  this  degree  the  gait  prolapses,  but  it  does  not 
protrude  from  the  anus.  The  sphincter  muscles  and  the  anal  aperture 
remain  normal.  The  patient  has  no  sensation  of  any  protrusion  when 
at  stool,  nor  is  there  any  soreness  or  pain  about  the  margin  of  the  anus. 

Speaking  from  a  mechanical  point  of  view,  this  degTee  is  only  the 
first  step  of  the  second  degree  of  procidentia,  only  it  is  higher  up,  and 
in  the  large  majority  of  cases  never  proceeds  to  actual  protrusion  through 
the  anus. 

Symptoms. — The  symptoms  of  this  condition  are  quite  obscure.  The 
patient  will  nearly  always  give  a  history  of  having  suft'ered  from  con- 


078  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

stipation,  but  after  a  protracted  period  of  this  disorder  he  may  develop 
an  irregular  diarrhoea.  In  whichever  state  he  is  found,  one  can  always 
elicit  the  fact  that  when  he  goes  to  stool  the  act  is  never  satisfactory. 
There  always  appears  to  be  something  more  to  come  away.  This  sensa- 
tion is  similar  to  that  produced  by  the  presence  of  a  foreign  body,  and 
often  results  in  straining  and  prolonged  sitting  at  the  toilet. 

Laxatives  are  never  satisfactory  in  their  effects.  Enemas  are  essen- 
tial to  a  comfortable  movement  of  the  bowels,  and  these  act  more  by 
raising  the  prolapsed  gut  upward  and  thus  relieving  the  intussusception 
than  by  stimulating  peristalsis.  Heaviness  and  weight  in  the  sacral  re- 
gion associated  with  dull,  aching  pains  radiating  to  the  thighs,  are  fre- 
quently complained  of.  At  other  times  there  is  aching  in  the  perinseum 
with  dysuria  and  disorders  of  the  sexual  functions.  In  some  cases  the 
author  has  observed  a  dragging  upon  the  lumbar  and  lower  abdominal 
regions.  Tlie  symptouis  are  very  likely  to  be  mistaken  for  ovarian  or 
tubal  diseases  in  women.  Flatulence,  intestinal  indigestion,  and  nui- 
cous  colitis  are  almost  constant  accompaniments  of  this  disorder. 

At  first  the  mucus  discharged  is  clear  like  the  white  of  an  egg;  after- 
ward it  becomes  tinged  with  blood  and  contains  a  suiall  quantity  of  pus. 
These  latter  changes  are  produced  by  the  friction  and  irritation  of  the 
mucous  membrane  due  to  the  prolapse  and  recession  of  the  gut,  causing 
first  a  stimulation  and  then  excoriation,  and  finally  idceration.  In 
Plate  I,  Fig.  6,  a  typical  ulceration  occurring  upon  the  crest  of  such 
a  prolapse  is  represented. 

Occasionally  there  is  associated  with  this  condition  a  so-called  mem- 
branous colitis  accompanied  by  marked  exhaustion,  and  sometimes  severe 
abdominal  pains  after  stool.  N"one  of  these  symptoms  is  uniformly 
present,  however,  with  the  exception  of  the  feeling  of  unfinished  busi- 
ness, flatulence,  and  irregularity  in  the  movement  of  the  bowels. 

Etiology. — The  causes  of  this  type  of  procidentia  are  various.  Any 
neoplasm  of  the  sigmoid  or  upper  portion  of  the  rectum  may  induce 
a  gradual  descent  until  the  growth  reaches  a  resting-place  in  the  am- 
j)ulla  of  the  rectum.  Whatever  causes  constriction  of  the  gut  and 
obstruction  to  the  fscal  passages  will  also  result  in  this  type  of  pro- 
lapse. Thus^  unusual  contracture  at  the  recto-sigmoidal  juncture, 
fibrous  or  malignant  strictures,  perirectal  strictures  or  ulcerations 
causing  spasmodic  contraction,  will  cause  the  arrest  of  the  faecal  masses 
above  these  points,  and  consequently  a  sagging  down  or  intussusception 
of  the  intestine  above  into  that  below.  Chronic  constipation  almost 
invariably  precedes  this  condition,  and  we  have  associated  with  it  a 
hypertrophic  catarrh  of  the  mucous  membrane  with  hyperemia  and 
thickening  of  the  walls.  The  ulcerations  which  are  occasionally  found 
in  this  condition  are  in  all  jirobjibility  the  result  of  it,  and  not  the 


PROLAPSE  OF  THE  RECTUM  679 

cause,  being  produced  by  the  constant  friction  of  the  gut's  slipping 
up  and  down.  In  the  cases  in  which  the  abdomen  has  been  opened 
for  the  purposes  of  fastening  the  gut  so  as  to  prevent  its  prolapse, 
the  author  has  always  found  an  abnormally  elongated  mesosigmoid  and 
mesorectum.  Elongated,  peritoneal  supports,  associated  with  intra- 
intestinal  neoplasms,  inflammation,  or  obstructions,  are  in  general  the 
causes  of  this  condition. 

Dr.  F.  Schmey  (Centrbl.  f.  Kinderheilk.,  1897,  Bd.  ii,  S.  41),  after 
an  extensive  experience  in  this  line,  states  that  the  large  majority  of 
prolapses  of  the  rectum  in  children  is  due  to  rhachitis.  In  elderly 
people  progressive  atony  of  the  intestinal  muscles  may  also  be  con- 
sidered as  a  predisposing  cause. 

Pathology. — To  understand  the  organic  changes  which  the  prolapse 
itself  involves,  it  is  necessary  to  refer  the  reader  once  more  to  the 
supports  of  the  rectum  (Chapter  I,  p.  47).  It  will  be  remembered  that 
the  latter  is  held  in  position  by  several  different  classes  of  supports. 
The  lower  portion  is  maintained  in  position  by  the  levator  ani  and 
external  sphincter  muscles,  the  perineal  fascia  and  fibrous  attach- 
ments to  the  coccyx,  and  the  prostatic  or  vaginal  walls;  the  middle 
portion  is  suj^ported  by  the  loose  fibrous  tissues  which  pass  off  from 
the  sacrum  along  the  course  of  the  lateral  sacral  arteries  and  line  the 
upper  surface  of  the  levator  ani,  thus  connecting  the  organ  with  the 
osseous  frame  of  the  pelvis.  The  superior  portion  is  held  in  position 
by  the  peritoneal  folds  which  connect  it  with  the  pelvic  walls  upon  the 
sides,  the  bladder  or  uterus  in  front,  and  with  the  sacrum  behind, 
where  the  mesorectum  and  mesosigmoid  comprise  the  chief  supj^ort 
of  the  gut. 

In  order  for  procidentia  to  occur  there  must  be  a  weakening  or 
destruction  of  these  supports  as  well  as  some  force  capable  of  dis- 
lodging the  organ  from  its  position.  The  passive  supports,  composed 
of  fibrous  and  elastic  tiss^^es,  lose  their  efficiency  through  gradual  elonga- 
tion or  rupture;  the  active  supports,  composed  of  muscular  tissues,  lose 
theirs  through  atrophy,  injury,  or  paralysis.  In  procidentia  of  the  first 
and  second  degrees  the  pathological  changes  consist  in  alterations  in 
the  muscular  apparatus  and  fibrous  attachments  of  the  lower  end  of  the 
rectum  to  the  surrounding  parts;  in  that  of  the  third  degree  the  altera- 
tions take  place  in  peritoneal,  vascular,  and  connective-tissue  supports. 
The  latter  condition  is  always  of  a  gradual  and  slow  development;  the 
former  may  come  on  suddenly  from  accident  or  injury,  or  it  may  develop 
gradually  from  the  extension  of  a  procidentia  of  the  third  degree.  In 
the  case  seen  with  Dr.  Ladinski  (Fig.  167),  where  the  prolapse  was  due 
to  a  marked  fibrous  stricture  6  inches  above  the  anus,  this  gradual  devel- 
opment was  undoubtedly  the  course  of  the  disease. 


680  THE  ANUS,   RECTUM,  AND   PELVIC   COLON 

In  traumatic  cases  the  prolapse  occurs  first,  and  the  atony  or  weak- 
ening of  the  muscles  is  secondary.  In  old  people  and  sodomists,  and 
in  children  that  have  suffered  from  exhausting  diseases,  the  relaxa- 
tion of  the  sphincters  is  primary  and  the  prolapse  secondary. 

Along  with  the  other  changes  which  occur,  there  is  the  absorption 
of  the  perirectal  fat  in  the  retro-rectal,  superior  pelvi-rectal,  and  ischio- 
rectal spaces. 

Treatment. — The  rational  treatment  of  complete  prolapse  of  the 
rectum  will  depend  upon  the  exciting  cause,  the  type,  and  the  actual 
pathological  changes  which  have  taken  place  in  the  organ  itself  and  the 
surrounding  tissues.  It  is  useless  to  suppose  that  a  procidentia  can  be 
cured  by  restoring  the  rectal  supports  if  the  exciting  cause  remains 
active.  Such  conditions  as  haemorrhoids,  neoplasms,  strictures,  and 
ulcerations  must  all  be  eradicated  before  a  permanent  result  can  be 
obtained.  All  the  methods  of  accomplishing  this  have  been  described 
in  their  proper  places.  Assuming,  therefore,  that  this  has  been  done 
and  the  prolapse  persists,  the  surgeon  must  proceed  to  restore  the 
rectal  supports  to  their  normal  condition. 

In  children  and  old  people  in  whom  this  condition  is  the  result  of 
constitutional  debility,  exhausting  diseases,  summer  diarrhoea,  dysen- 
tery, rhachitis,  or  general  senile  muscular  relaxation,  together  with  de- 
creased sensitiveness  to  normal  stimuli,  one  will  obtain  the  best  results 
by  the  treatment  of  these  conditions.  Schmey  states  that  nearly  all 
prolapses  in  children  may  be  radically  cured  by  the  administration  of 
phosphorus  in  increasing  doses.  He  recommends  the  following  pre- 
scription : 

^  B.  phosphor 0.01; 

01.  jecoris  aselli 100.0. 

Ft.  sol. 

Sig.:  One  to  three  coffee-spoonfuls  daily. 

The  author  has  long  taught  that  procidentia  in  the  young  is  ordi- 
narily amenable  to  very  conservative  methods.  Many  of  the  cases 
occur  in  ^veak,  debilitated  children  suffering  either  from  rhachitis  or 
the  result  of  some  exhausting  disease,  and  constitutional  treatment, 
such  as  has  been  advised  by  Dr.  Schmey,  will  be  necessary  in  all  of 
them.  Phospliorus  in  some  form,  strychnine,  hypophosphites,  cod-liver 
oil,  and  arsenic  are  useful  adjuvants  in  the  treatment.  These  all  act, 
however,  in  restoring  the  muscular  supports  by  toning  up  the  levator 
ani,  the  sphincters,  and  the  longitudinal  muscles  of  the  gut.  It  is  a 
matter  of  the  utmost  importance  that  the  prolapse  should  be  kept  in 
position  as  much  as  possible  while  these  drugs  are  restoring  the  re- 
tentive powers. 


PROLAPSE   OP   THE  RECTUM  681 

It  is  a  well-established  fact  that  if  an  intestine  is  held  in  one  posi- 
tion for  several  weeks,  it  will  become  fixed  at  that  point,  and  only 
be  removed  from  it  by  some  unusual  force.  The  secret  of  success 
in  the  treatment  of  prolapsus  recti  in  children  lies  in  our  ability  to 
maintain  the  organ  in  its  natural  position  while  the  general  consti- 
tutional condition  and  muscular  tone  are  being  restored  to  normal. 
In  addition,  therefore,  to  the  constitutional  treatment  of  these  cases, 
local  applications,  such  as  stimulate  contraction  of  the  sphincter  mus- 
cles and  retraction  of  the  prolapsed  gut,  should  be  frequently  made. 
Cold  water  is  one  of  the  best  of  such  applications;  solutions  of  alum 
or  tannic  acid  applied  to  the  prolapsed  gut  often  act  with  good  efi'ect. 
Where  the  prolapsus  is  oedematous  and  swollen,  excellent  results  may 
be  obtained  from  the  application  of  an  absorbent  pad  soaked  in  a  25- 
per-cent  solution  of  boroglyceride. 

In  order  to  prevent  the  prolapse  of  the  gut  during  the  act  of  defeca- 
tion, the  child  should  be  forced  to  use  the  bedpan,  or,  what  is  better 
still,  to  have  its  movements  while  lying  on  the  side,  the  bed  or  table 
being  protected  by  pads  of  cotton,  oakum,  or  some  other  substance  which 
can  be  destroyed.  In  order  to  facilitate  these  movements  and  avoid 
straining,  it  is  better  to  give  the  child  an  enema  just  before  laying  it 
in  position. 

Where  the  prolapsus  occurs  at  other  times  than  when  at  stool,  or 
when  it  remains  down  except  when  replaced  by  manual  efforts,  some 
method  will  be  necessary  to  maintain  the  gut  in  position  while  the 
alterative  processes  are  going  on.  There  is  no  better  means  of  accom- 
plishing this  than  broad  adhesive  straps  used  in  the  manner  advised 
by  Dr.  Powell,  of  New  York.  The  application  of  these  straps  is  made 
while  the  bowel  is  reduced  and  while  the  child  is  lying  upon  its  side; 
they  should  be  about  3  inches  wide,  and  should  pass  from  one  trochanter 
to  the  other,  the  buttocks  being  drawn  closely  together  and  folded  in; 
the  posterior  edge  of  the  strap  should  pass  Just  in  front  of  the  margin 
of  the  anus.  Ordinarily  these  straps  are  applied  directly  over  the 
anus,  so  that  they  must  be  removed  every  time  the  child  defecates; 
this  is  a  mistake,  because  frequent  reapplications  bring  on  an  irritation 
of  the  tender  skin,  and  it  soon  becomes  ulcerated.  If  the  strap  is 
placed  in  front  of  the  anus,  the  child  may  lie  upon  its  side  or  upon 
the  bedpan  and  defecate  without  soiling  it  or  necessitating  its  removal 
more  than  once  in  a  week  or  ten  days. 

Compresses  for  supporting  a  prolapsed  anus  are  not  satisfactory  in 
accomplishing  the  result,  and  at  the  same  time  by  their  pressure  upon 
the  sphincter  they  cause  dilatation  and  relaxation  of  this  muscle,  and 
thus  practically  prevent  the  very  end  that  is  sought.  In  old  people, 
who  constitute  the  greatest  number  of  cases  of  prolapses,  with  the  ex- 


682  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

ception  of  children,  there  is  a  different  cause  for  the  condition.  Often 
there  are  neoplasms,  hasmorrhoids,  strictures,  chronic  constipations, 
and  other  diseases  of  the  rectum  associated  with  an  absorption  of  fat 
from  the  perirectal  spaces,  a  general  decline  in  muscular  tone,  and  a 
decrease  in  nervous  sensibility.  Rhachitis  is  not  an  element  in  these 
cases  so  much  as  general  muscular  atony. 

The  constitutional  treatment  is  of  importance,  but  one  can  not 
expect  to  restore  the  waning  powers  of  age  and  accomplish  such  favor- 
able results  by  it  as  in  children.  At  the  same  time,  it  should  be  used, 
and  especially  in  the  forms  of  strychnine  and  arsenic.  The  local  appli- 
cations mentioned  above  are  useful  in  these  cases,  and  adhesive  straps 
may  also  be  of  benefit. 

Allingham  and  others  recommend  the  use  of  rectal  plugs  for  the 
retention  of  prolapsus,  and  claim  to  have  obtained  good  results  from 
them;  but  they  can  only  be  of  temporary  benefit  in  retaining  the  rec- 
tum in  position,  and  must  ultimately  do  injury,  as  they  constantly 
dilate  the  sphincter  and  by  their  presence  reduce  its  response  to  normal 
stimulation. 

Electricity,  both  galvanic  and  faradic,  has  proved  useful  in  these 
cases.  A  number  of  cases  have  been  reported  in  which  this  agent 
has  produced  a  complete  cure  of  the  disease,  both  in  children  and 
old  people.     General  massage  is  also  of  benefit. 

In  old  people  it  is  a  matter  of  great  importance  to  regulate  the 
bowels,  and  to  obviate,  as  far  as  possible,  prolonged  sitting  at  stool. 
If  the  prolapse  is  of  recent  occurrence,  it  is  well  to  have  the  patient 
use  a  bedpan  or  lie  upon  the  side,  as  advised  for  children,  for  the 
movement  of  the  bowels.  Laxatives  may  be  employed,  but  they  should 
not  be  drastic  or  griping  cathartics.  Small  enemas  of  cold  water  will 
generally  serve  to  produce  an  action  without  much  peristalsis  or  strain- 
ing. The  patient  should  be  taught  to  have  a  regular  time  for  going 
to  stool.  He  should  take  his  enema  lying  down,  and  repair  to  the 
toilet  only  when  he  feels  an  urgent  call  for  relief. 

The  length  of  time  which  these  non-operative  methods  should  be 
continued  will  depend  entirely  upon  the  history  of  the  case  and  the 
extent  of  the  prolapse.    Two  or  three  months  will  suffice  to  test  them. 

In  children  there  sometimes  occurs  an  extensive  prolapse,  coming 
on  suddenly  and  involving  considerable  lengths  of  intestine.  This  may 
be  brought  on  by  accident,  such  as  great  pressure  upon  the  abdomen, 
being  run  over  by  carriages,  or  falls  from  considerable  heights,  and 
also  from  acute  enteritis  with  great  tenesmus  and  straining.  If  seen 
early  and  the  parts  are  restored  and  held  in  position  by  straps,  the  pro- 
lapsus may  not  recur.  If,  however,  it  continues  to  do  so,  some  radical 
operative  interference  will  be  necessary.     In  general,  one  may  say  that 


PROLAPSE  OF  THE  RECTUM  683 

M'here  the  parts  are  irritated,  causing  the  child  distress,  and  where 
the  prolapsus  is  increasing  instead  of  decreasing,  operative  interfer- 
ence should  be  undertaken.  One  other  condition  also  demands  immedi- 
ate interference,  and  that  is  where  there  is  a  large  extent  of  pro- 
lapsus, spasm  of  the  sphincter,  and  great  turgescence  or  strangury  of 
the  prolapsed  gut.  Under  such  conditions  delay  is  unjustifiable,  and 
operative  interference  should  not  be  put  off. 

Strangury  and  sloughing  from  prolapsus  of  the  rectum  is  very  rare 
in  children  and  old  people.  It  occurs  in  adults  and  middle-aged  indi- 
viduals, and  the  sloughing  even  then  is  generally  limited  to  the  mucous 
membrane.  There  are  cases,  however,  reported  in  which  the  whole 
prolapsed  gut  has  sloughed  off,  and  thus  a  spontaneous  cure  of  the 
procidentia  has  resulted.  In  these  cases  there  has  always  followed  a 
cicatricial  contraction  or  stricture  which  has  been  very  difficult  to 
manage.  The  dangers  from  such  a  process,  and  the  unsatisfactory 
final  result,  absolutely  forbid  dilatory  action  in  these  conditions. 

Reduction. — Ordinarily  prolapses  of  the  rectum  are  reduced  spon- 
taneously or  can  be  easily  replaced  by  the  patients  themselves.  Some- 
times, in  excessive  cases  or  in  those  produced  by  accident,  the  patient 
is  unable  to  reduce  the  gut,  and  the  surgeon  is  called  in  for  this  pur- 
pose. If  the  procidentia  has  been  down  for  any  length  of  time  and 
the  sphincter  is  tightly  contracted  around  it,  there  may  be  great  swell- 
ing and  oedema  of  the  tissues,  and  the  difficulties  of  reduction  will  be 
found  by  no  means  slight. 

The  methods  to  be  employed  in  such  cases  are  various,  and  each 
case  will  present  a  problem  in  itself.  It  is  advisable  that  the  replace- 
ment should  be  made  without  general  ansesthesia,  if  possible,  in  order 
to  avoid  the  subsequent  nausea  and  straining  which  will  tend  to  repro- 
duce the  procidentia.  If,  however,  after  due  manipulation  the  reduc- 
tion can  not  be  accomplished,  one  should  not  hesitate  to  administer 
it,  stretch  the  siDhincter,  and  reduce  the  procidentia. 

When  called  to  a  case  of  unreduced  prolapsus,  one  should  carefully 
examine  the  parts  to  determine  whether  it  is  complete  or  incomplete. 
The  condition  of  the  mucous  membrane  should  also  be  carefully  exam- 
ined to  note  if  strangury,  ulceration,  or  sloughing  has  taken  place. 
These  conditions  will  depend,  of  course,  upon  the  length  of  time  which 
the  gut  has  been  down  and  the  amount  of  constriction.  If  there  is 
great  congestion  or  oedema,  firm  pressure  Avith  hot  cloths  should  be 
made  for  some  time  before  any  attempt  at  reduction.  Cold  is  never 
advisable  in  these  cases,  as  the  circulation  is  always  deficient,  and  one 
may  bring  on  sloughing  by  its  use. 

Applications  of  cocaine  and  suprarenal  extract  will  assist  in  con- 
tracting the  blood-vessels  and  reducing  the  volume  of  the  prolapse. 


684  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

The  patient  should  be  placed  in  the  knee-chest  posture  or  in  Sims's 
position,  with  the  hips  well  elevated,  the  former  being  by  all  means 
the  best  to  reduce  the  amount  of  blood  in  the  parts,  and  also  to  obtain 
the  influence  of  gravitation  upon  the  upper  end  of  the  intestine,  thus 
assisting  in  its  reduction.  By  this  position  a  hernia,  if  present,  will 
be  reduced,  and  often  after  this  the  prolapse  will  retire  spontaneously. 
After  gentle  and  continued  pressure  with  hot  compresses  and  the  appli- 
cations mentioned,  one  will  generally  find  that  the  circulation  of  the 
parts  is  improved,  and  the  oedema  and  congestion  will  have  greatly  dis- 
appeared. Efforts  at  reduction  may  then  be  begun,  and  they  should 
always  be  directed  through  the  lumen  of  the  bowel  at  the  end  of  the 
prolapse.  Allingham  states  that  whenever  this  lumen  points  backward 
toward  the  sacrum  one  may  conclude  that  there  is  hernia  of  the  small 
intestine  along  with  the  prolapse.  This  is  not  always  so,  for  the  author 
has  seen  one  ease  in  which  the  lumen  was  twisted  almost  to  the  sacrum, 
and  yet  in  which  there  was  no  hernia  present.  Great  care  should  be 
exercised  in  the  manipulation  that  one  docs  not  bruise  or  irritate  the 
parts.  In  order  to  carry  the  inner  layer  of  the  prolapsed  gut  upward, 
the  finger  or  a  bougie  should  be  gently  introduced  into  its  lumen  and 
carried  upward,  thus  undoing  the  outward  invagination  and  shortening 
the  prolapsus.  In  order  to  accomplish  this  the  bougie  should  not  be 
oiled,  as  it  will  then  slide  over  the  mucous  membrane  and  not  carry 
the  gut  upward.  An  ingenious  device  is  to  wrap  a  small  piece  of 
tissue  paper  around  one's  finger,  introduce  its  end  into  the  lumen  of 
the  prolapse,  and  gently  push  upward.  By  this  means  the  inner  layer 
of  the  prolapsus  is  carried  upward,  while  the  outer  layer  is  little  by 
little  enfolded  on  the  finger.  Having  reduced  the  prolapsus  thus  far 
by  a  boring  motion,  the  finger  is  released  from  the  tissue  paper  and 
withdrawn;  the  paper  remains  and  assists  in  preventing  the  prolapsus 
from  recurring.  This  procedure  is  repeated  until  the  entire  prolapsus 
is  reduced.  The  same  method  may  be  applied  with  a  small  rectal  bou- 
gie, but  in  the  writer's  experience  the  finger  has  been  all  that  is  neces- 
sary to  accomplish  the  reduction.  A  full  dose  of  morphine  adminis- 
tered hypodermically  is  sometimes  of  great  assistance  in  the  accom- 
plishment of  the  reduction.  Where  the  sphincter  is  so  tight  that  it 
constricts  the  gut  and  prevents  its  return,  one  should  not  consume 
valuable  time  in  lengthy  and  vigorous  taxis,  but  resort  to  the  use 
of  general  anaesthesia,  stretch  this  muscle,  and  accomplish  the  re- 
duction. 

Eedudion  in  Gangreiwns  Conditions. — When  sloughing  has  taken 
place,  one  should  be  very  careful  to  determine  its  depth  before  attempt- 
ing to  reduce  the  prolapsus.  If  the  walls  of  the  gut  have  become  gan- 
grenous, or  likely  to  perforate,  it  will  be  very  dangerous   to  reduce 


PKOLAPSE   OF   THE   RECTUM  685 

such  a  condition,  inasmuch  as  it  might  open  into  the  peritoneal  cavity 
and  thus  produce  a  fatal  peritonitis.  In  such  cases  immediate  amputa- 
tion should  be  resorted  to  instead  of  waiting  until  the  slough  comes 
away  spontaneously,  because  under  such  circumstances  the  upper  end 
of  the  gut  may  retract  and  thus  open  the  peritoneal  cavity  and  allow 
all  the  contents  of  the  bowels  to  be  emptied  into  it.  By  immediate 
amputation  the  upper  end  can  be  caught  and  fixed  by  sutures  or  for- 
ceps until  inflammatory  adhesion  shuts  ofl'  the  peritoneal  cavity,  and 
such  dangers  are  avoided. 

After  the  reduction  of  the  prolapsed  mass,  the  questioi>of  future 
treatment  will  arise.  If  the  procidentia  is  acute,  whether  due  to  acci- 
dent or  to  other  sudden  causes,  a  compress  may  be  applied  to  the 
anus,  the  buttocks  strapped  together,  the  patient  confined  to  bed,  and 
his  bowels  moved  in  a  reclining  posture,  until  it  is  seen  whether  the 
prolapsus  will  recur.  Sometimes  it  happens  that  the  gut  remains  in 
situ,  and  no  further  treatment  is  necessary.  But  if  the  case  be  one 
of  long  standing  and  gradual  increase,  some  operative  method  for  its 
retention  will  be  necessary. 

Operative  Treatment. — As  will  be  recognized  from  the  foregoing 
description  of  the  kinds  and  causes  of  prolapsus,  the  method  to  be 
selected  will  depend  upon  the  point  at  which  the  prolapse  begins  and 
the  extent  to  which  it  descends.  In  procidentia  of  the  first  degree,  in 
which  only  a  small  portion  of  the  lower  end  of  the  gut  comes  down, 
those  methods  which  narrow  the  anus  and  thus  obviate  the  protrusion 
will  be  etfectual.  But  if  the  prolapsus  begins  high  up,  and  there  is  a 
cul-de-sac  between  it  and  the  anal  margin,  such  methods,  while  pre- 
venting the  protrusion,  will  simply  convert  a  procidentia  of  the  second 
degree  into  one  of  the  third  degree,  and  will  in  all  probability  prove 
of  no  permanent  benefit.  The  principles  upon  which  the  cure  of  proci- 
dentia depends  are,  first,  the  removal  of  any  exciting  cause;  and, 
secondly,  the  restoration  of  the  supports  which  have  been  altered  or 
destroyed.  It  can  therefore  be  seen  that  if  the  prolapse  be  due  to 
stretching  or  rupture  of  the  passive  supports,  it  will  be  necessary  to 
restore  these  or  to  devise  others  to  take  their  places  before  the  pro- 
lapse can  be  radically  cured;  and  if  it  be  due  to  relaxation,  overstretch- 
ing, dilatation  or  paralysis  of  the  muscles,  the  treatment  must  be 
directed  to  the  restoration  of  the  normal  condition  in  these  parts. 
In  complete  prolapsus  of  the  first  and  second  degrees,  we  have  to  deal 
with  rupture  or  elongation  of  the  adhesions  between  the  lower  end  of 
the  rectum  and  the  surrounding  tissues,  especially  its  attachments  to  the 
coccyx,  sacrum,  and  prostate  or  vagina,  together  with  muscular  atony 
or  relaxation.  Appreciating  these  facts,  AUingham  and  Tan  Buren 
devised  methods  for  restoring  the  adhesions  between  the  rectum  and 


686  THE  ANUS.   RECTUM,   AND   PELVIC   COLON 

these  parts  by  setting  up  an  inHammation  in  the  walls  of  the  gut,  and 
thus  causing  agglutination  with  the  perirectal  tissues. 

Allingliams  Method. — This  consists  in  the  application  of  nitric  acid 
or  acid  nitrate  of  mercury  to  the  prolapse.  The  patient  is  anesthetized 
and  the  gut  brought  down,  washed  off,  and  dried.  "  The  acid  must 
be  applied  all  over  it,  care  being  taken  not  to  touch  the  verge  of  the 
anus  or  the  skin.  The  part  is  then  to  be  oiled  and  the  rectum  stuffed 
with  wool.  A  pad  must  after  this  be  applied  outside  the  anus  and 
kept  firmly  in  position  by  a  strapping  plaster,  the  buttocks  being  by 
the  same  onovements  brought  closely  together;  if  this  precaution  be 
not  adopted,  when  the  child  recovers  from  the  chloroform  (the  strain- 
ing being  urgent)  the  whole  plug  will  be  forced  out  and  the  bowel  will 
again  protrude.  When  the  pad  is  properly  applied  the  straining  soon 
ceases  and  the  child  suffers  little  or  no  pain."  The  bowels  are  con- 
fined for  four  days;  after  this  the  strap  is  removed  and  castor-oil  is 
administered  to  move  them.  He  states  that  the  treatment  is  chiefly 
applicable  to  procidentia  in  children,  and  rarely  fails  if  properly  car- 
ried out,  but  sometimes  it  is  necessary  to  apply  the  acid  more  than 
once.  The  author  has  never  had  the  temerity  to  employ  this  method 
as  advised  by  Allingham. 

Theoretically,  it  appears  that  so  strong  an  agent  applied  to  the 
entire  mucous  membrane  of  the  gut  would  produce  a  sloughing  and 
subsequent  ulceration  which  would  result  in  stricture.  There  is  abso- 
lutely no  control  over  the  action  of  the  acid  and  the  depth  to  which 
it  will  burn.  Whether  this  burning  is  any  more  severe  in  the  tender 
tissues  of  the  child  than  in  the  adult  is  questionable,  but  certainly 
the  walls  of  the  intestine  are  thinner  in  children,  the  blood  supply  is 
more  feeble,  and  sloughing,  it  seems,  would  be  more  probable.  The 
author  has  used  nitric  acid,  however,  as  follows:  A  very  small  quantity 
of  absorbent  cotton  is  wrapped  around  a  long  platinum  or  wooden  ap- 
plicator and  dipped  into  the  acid;  this  is  laid  upon  the  prolapsing  gut  at 
points  about  ^  an  inch  apart  around  the  rectum,  so  as  to  produce  linear 
cauterization  and  leave  healthy  strips  of  mucous  membrane  between 
them.  These  are  carried  from  the  margin  of  the  anus  to  the  highest 
portion  of  the  prolapse,  the  lumen  being  held  open  by  small  retractors 
while  the  applications  are  made.  The  dressing  and  after-treatment  em- 
ployed have  been  the  same  as  Allingham's,  except  that  a  drainage-tube 
extending  above  the  packing  was  introduced  to  allow  the  escape  of  gases. 

Van  Buren's  Method. — The  patient  is  anassthetized,  the  prolapsus 
is  dragged  down  as  far  as  it  will  come,  thoroughly  washed  off,  and 
dried;  the  actual  cautery  is  applied  in  lines  about  ^  an  inch  apart 
all  around  the  circumference  of  the  gut,  extending  from  the  margin 
of  the  anus  to  the  highest  point  of  the  prolapsus.     A  cauterizing  iron 


PROLAPSE  OP  THE  RECTUM  687 

or  a  Paquelin  cautery,  heated  to  a  bright  lieat,  may  be  used.  Van 
Buren  says  that  the  latter  instrument  is  not  suitable  for  this  purpose 
on  account  of  its  not  maintaining  its  heat  long  enough.  The  author, 
however,  has  found  it  very  satisfactory  for  this  purpose.  A  narrow 
blade  should  be  used  so  as  to  make  the  cauterization  deep  but  not 
wide.  The  tissues  should  be  burned  down  to  the  muscular  wall  of 
the  gut,  care  being  taken  not  to  perforate  this  layer,  especially  on  the 
anterior  surface  of  the  gut,  because  in  this  region  the  peritonaeum 
may  be  involved,  and  too  deep  cauterization  might  penetrate  its  cavity 
and  thus  produce  a  peritonitis.  After  the  cauterization  has  been  ac- 
complished, the  parts  should  be  well  oiled  and  reduced.  A  drainage- 
tube  should  be  introduced  above  the  height  of  the  prolapse,  and  around 
it  there  should  be  packed  a  mass  of  wool  or  gauze,  well  oiled,  in  order 
to  retain  the  rectal  walls  in  close  apposition  with  the  surrounding 
parts.  A  compress  should  be  applied  to  the  anus  and  held  in  position 
with  an  adhesive  strap  which  draws  the  buttocks  together.  The 
bowels  should  be  confined  for  four  or  five  days  and  the  patient  kept 
in  a  recumbent  posture.  At  the  end  of  this  period  an  enema  should 
be  given  through  the  drainage-tube,  and  the  patient's  bowels  moved 
while  on  his  side  or  back.  The  gauze  packing  will  be  expelled  with 
the  movement  of  the  bowel,  and  generally  the  prolapsus  will  not  recur. 
The  patient  should  be  required  to  move  his  bowels  in  the  reclining 
posture  for  two  or  three  weeks. 

These  methods  are  often  successful  in  the  treatment  of  prolapsus 
of  the  first  degree  if  they  are  applied  in  the  early  stages;  but  if  the 
condition  is  neglected  until  the  prolapsus  becomes  very  large  and  the 
walls  thickened  and  hypertrophied,  they  are  not  likely  to  result  in  per- 
manent cure.  In  grown  people,  Allingham  himself  does  not  place  much 
confidence  in  his  method.  He  states  that  the  applications  do  good, 
but  that  the  relief  is  only  temporary.  The  free  application  of  acid 
to  old  people  with  broken-down  constitutions,  he  says,  is  likely  to  pro- 
duce deep  sloughing  and  subsequent  hemorrhage.  He  also  admits  that 
it  may  produce  stricture,  and  he  cites  the  case  of  a  girl  in  whom  such 
a  result  did  occur,  although  the  prolapsus  was  cured.  The  Van  Buren 
method  is  more  frequently  successful,  but  it  is  only  applicable  to  cases 
of  the  first  degree.  If  the  prolapse  involves  the  upper  portions  of 
the  rectum,  those  surrounded  by  the  peritonaeum,  it  is  perfectly  clear 
that  methods  which  depend  upon  inflammatory  adhesion  of  the  gut 
to  the  surrounding  tissues  will  be  comparatively  useless. 

"Where  the  prolapse  is  of  small  extent,  the  removal  of  folds  of 
mucous  membrane  at  four  or  five  points  around  its  circumference  by 
the  clamp  and  cautery,  as  advised  by  Mr.  Henry  Smith,  has  frequently 
proved  entirely  successful.     One  may  also,  in  this  class  of  cases,  dissect 


688 


THE  ANUS,   RECTUM,  AND  PELVIC   COLON 


oil  elliptical  strips  of  mucous  incnibraue,  bringing  the  edges  together 
with  silkworm-gut  or  chromieized  sutures,  thus  narrowing  the  lower 
end  of  the  rectal  canal,  and  overcome  the  prolapse  for  the  time  being. 
The  permanency  of  such  relief  is  very  doubtful. 

Buret's  operation  (Bull,  et  mem.  de  la  soc.  de  chir.,  Paris,  1900,  p. 
470),  known  as  rectorrhaphy,  first  reported  in  a  thesis  by  j\Iasson, 
189-1,  is  similar  to  that  done  for  prolapsus  vaginse.  Upon  the  an- 
terior and  posterior  surfaces  of  the  prolapsus  an  elliptical  flap  of 
mucous  membrane  is  dissected  out,  extending  from  the  summit  to 
the  base,  thus  leaving  two  lateral  pillars  of  mucous  membrane.  The 
muscular  walls  are  folded  in  by  buried  silk  sutures  and  the  edges  of 
the  mucous  membrane  approximated  by  superficial  ones.  By  this  means 
the  cavity  of  the  ampulla  is  changed  into  a  regular  cylinder  of  small 

caliber  (the  same  as  is 
done  in  colporrhaphy). 
Finally,  he  removes 
triangular  flaps  of  skin 
from  the  margin  of  the 
anus  and  sutures  the 
edges  of  the  wounds 
together,  thus  narrow- 
ing this  orifice  both 
anteriorly  and  posteri- 
orly. In  a  case  oper- 
ated on  in  1894  after 
this  method,  and  ex- 
amined twenty  months 
later,  the  result  was 
perfect.  This  opera- 
tion is  only  a  modifi- 
cation of  the  Dupuy- 
tren  method,  and  will 
accomplish  nothing 
more  than  the  clamp 
and  caute^v^ 

In    minor    degrees 
of  procidentia  the  con- 
FiG.  227.— Delorme's  (Jperatkjx  fok  Pkocidentia  Recti.       dition   may   somctimes 

be  relieved  by  some 
modification  of  the  ^Miitehead  operation.  The  mucous  membrane  is 
dissected  from  the  prolapse,  excised,  and  the  cut  borders  sutured  to 
the  margin  of  the  anus,  thus  tucking  or  folding  in  that  portion  of  the 
gut  which  was  prolapsed.     Delorme  (Bull,  et  memoires  de  la  soc.  de 


PROLAPSE    OF    THE   RECTUM 


689 


Fig.  2-2S. — Dzlokiee's  Opeeatiox  completed,  shcsvixs 
EEDrpxiCATiox  or  Eectal  Wall. 


chirur.,  Paris,  1900,  j).  -199)  advi-ses  this  operation  even  in  large  jjro- 
lapses  of  1:  to  6  inches  in  extent.  He  give.?  an  elaborate  description 
of  how  the  mucous  mem- 
brane is  dissected  from  the 
prolapse  (Fig.  22"),  prac- 
tically denuding  the  entire 
rectum.  It  is  cut  off  and 
then  sutured  to  the  muco- 
cutaneous border.  The 
thickened  and  freshened 
surfaces  of  the  gut  are 
thus  invaginated  above 
the  line  of  sutures.  He 
claims  that  this  reduplica- 
tion (Fig.  228)  not  only 
produces  a  narrowing  of 
the  canal,  but  also  in- 
creases the  sphincteric 
action,  which  is  beneficial 
to  the  patient.  He  re- 
ports 3  eases  in  which  he 
removed  20,  30,  and  80 
centimeters   (about   8,   12, 

and  30  inches)  of  the  mucous  membrane,  obtaining  excellent  results  in 
the  first  2  cases  and  death  from  septic  peritonitis  in  the  third.  It 
is  impossible  to  conceive  that  such  a  method  would  not  result  in  stric- 
ture at  the  lower  end  of  the  rectum.  It  has  this  one  advantage,  how- 
ever, that  in  cases  due  to  hernias  through  the  rectal  cul-de-sac,  this 
thickened  ring  will  furnish  an  obstacle  to  the  descent  of  the  peritoneal 
pouch,  and  thus  effectually  prevent  the  recurrence  of  the  prolapse. 

These  operations,  limited  to  the  mucous  membrane,  have  often 
proved  ineffectual,  and  many  procedures  involving  the  deeper  tissues 
have  been  devised.  The  principal  ones  are  those  of  Eoberts,  Dieffen- 
bach,  Lange,  Yerneuil,  and  Peters. 

The  Dieffenbach-Pioberts  operation  consists  in  the  removal  of  a 
section  of  the  gut  at  its  posterior  commissure,  extending  about  2  inches 
upward.  The  entire  thickness  of  the  intestine  vrith  the  sphincter  mus- 
cles are  removed,  and  the  caliber  of  the  lower  end  of  the  rectum  and 
anus  is  thus  greatly  reduced.  The  success  of  the  operation  depends 
upon  primary  union  of  the  parts.  If  this  fails,  it  is  liable  to  result 
in  an  increase  of  the  prolapse,  together  with  incontinence  of  fasces. 
The  operation  is  not  applicable  to  prolapses  beginning  high  up,  as  it 
does  not  affect  the  original  cause. 
44' 


690 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


Fig.  229. — Infolding  of  the  Glt  in 
Peters''s  Operation  for  Procidentia 
Recti. 


Lange  has  advised  infolding  the  rectal  ampulla  from  the  outside, 
thus  narrowing  the  canal  so  as  to  prevent  the  prolapse.  His  opera- 
tion consists  in  making  an  incision  from  the  posterior  margin  of  the 

anus  upward  alongside  of  the  coc- 
cyx,  and   deep   enough  to  expose 
the  posterior  wall  of  the  rectum. 
The  levator  ani  muscle  is  dissected 
off,  and  the  walls  of  the  gut  are 
then  infolded  by  a  line  of  sutures 
introduced  through  the  musciilar 
layer,  tlius  narrowing  the  caliber 
and  stiffening  the  wall  to  such  an 
extent  as  to  prevent  the  prolapse. 
Yerneuil  (Gaz.  des  hopitaux.  May 
2,  1893)  modified  Lange's  method  by  gathering  the  gut  in  horizontal 
folds,  thus  shortening  it,  after  which  he  sutured  it  to  the  sides  of  the 
coccyx  and  sacrum  by  buried  sutures  and  closed  the  external  wound. 
Peters  (International  Text-Book  of  Surgery)  advocates  an  operation 

similar  to  this  upon  the      ■  

anterior    wall     of    the  ' 

rectum.  He  makes  an 
abdominal  incision  in 
the  median  line  large 
enough  to  admit  of  the 
manipulation  of  the  an- 
terior wall  of  the  rec- 
tum in  the  peritoneal 
pouch.  The  prolapse 
having  been  drawn  up- 
ward by  dragging  on 
the  sigmoid,  the  an- 
terior wall  of  the  gut 
is  infolded  by  Lembert 
sutures  (Fig.  229),  the 
ends  of  which  are  left 
long,  and  pass  through 
the  muscular  layer  of 
the  abdominal  wall, 
thus  forming  a  sort  of 
sling    to    support    the 

rectum  (Fig.  230).  The  adhesion  of  the  peritoneal  surfaces  nar- 
rows the  caliber  of  the  rectum  and  thus  obviates  the  recurrence  of 
the  prolapse. 


Fig.  230. — Attachment  of  the  Gut  to  the  Abdominal 
Wall  in  Peteks's  Operation. 


PROLAPSE   OF   THE   RECTUM 


691 


Xoue  of  these  methods,  with  the  exceptiou  of  A'erneuil's,  accom- 
plishes anything  more  than  narrowing  of  the  anal  outlet  and  an  inflam- 
matory adhesion  of  the  extreme  lower  end  of  the  rectum  to  the  sur- 
rounding parts.  As  a  consequence  they  all  fail  to  retain  prolapses  of 
considerable  magnitude.  George  E.  Fowler  (Med.  News,  X.  Y.,  Feb- 
ruary' 27,  1897)  first  practised  suspending  the  rectum  by  sutures  car- 
ried around  the  coccyx.  He  is  therefore  entitled  to  priority  in  the 
application  of  a  principle  which  the  author  employs  as  follows: 

Bedopexy  or  Suspension  of  the  Rectum  upon  tTie  Sacrum. — The  patient 
is  prepared  by  thorough  cleansing  of  the  intestinal  canal,  shaving  the 
P'":'rina?uni  and  sacral  region,  and  applying  an  antisejotic  dressing  the 


Fi. 


-i:f. 


T'iPKXY    F'Jl: 


I'R^ 


i;k. 


night  before  the  contemj^lated  operation.  After  being  anEesthetized  he 
is  placed  in  the  semiprone  position  on  the  left  side  with  the  hips  eleyated 
on  pillows  and  the  thighs  well  flexed  on  the  abdomen.  The  prolapse  is 
then  dragged  down  to  its  full  extent  and  held  forward  by  an  assistant. 
A  curved  incision  about  2  inches  in  length  is  made  midway  between  the 
coccyx  and  anus  (Fig.  231).  This  is  carried  through  all  the  tissues 
into  the  retro-rectal  space.  "With  the  fingers  or  a  dull  instrument 
introduced  through  this  incision,  the  rectum  is  separated  from  the 
coccyx  and  sacrum  posteriorly  as  high  up  as  the  attachment  of  the 
mesorectum  and  on  the  sides  as  far  as  the  attachment  of  the  lateral 
ligaments.     The  latter  should  be  sedulously  preserved.     The  anterior 


692 


THE  ANUS,  RECTUM,   AND   PELVIC  COLON 


surface  of  the  bone  is  then  gently  eurettud  to  remove  all  the  fatty 
tissue  and  freshen  it.  At  this  point  tlie  assistant  reduces  the  prolapse, 
and  with  his  fingers  inside  the  gut  inverts  and  brings  it  out  through  the 
incision  (Fig.  232);  the  operator  catches  the  jjrotrusion  and  drags  the 


Fig. 


-KeCTOPEXY THE    GdT   INVERTEFt    AXD    BROrfillT   THHOUGH    THE    Ixf'ISION;    THE 

Sutures  passed  through  its  Muscular  Walls. 


gut  down  as  far  as  it  will  come,  usually  a  little  less  than  the  amount 
prolapsed  through  the  anus.  The  external  surface  or  muscular  wall 
of  the  gut  thus  exposed  is  then  curetted  as  was  the  sacrum.  Silkworm- 
gut  or  silver-wire  sutures  are  then  passed  transversely  through  the 
muscular  layer,  embracing  as  much  of  the  circumference  of  the  gut 
as  possible;  they  are  placed  ^  inch  ajiart,  and  the  ends  left  6  to  8 
inches  long.  After  the  sutures  have  been  placed,  the  ends  of  the 
upper  ones  are  each  in  turn  threaded  on  a  long,  curved  Peasley's 
needle  and  carried  up  through  the  wound  to  the  highest  point  of  the 
separation  between  the  rectum  and  sacrum,  where  they  are  made  to 
penetrate  the  tissues,  and  are  lu'ought  out  through  the  skin  on  opposite 
sides  of  the  bone.  The  other  sutures  are  treated  in  like  manner,  each 
being  brought  out  ^  inch  lower  than  the  preceding  one  (Fig.  233). 
The  ends  are  then  drawn  taut,  and  the  prolapse  is  thus  dragged  up 
into  the  hollow  of  the  sacrum  where  it  belongs.  A  pad  of  gauze  is 
laid  over  the  sacrum,  and  the  sutures  tied  over  this  to  avoid  their 
cutting  into  the  skin  (Fig.  234).     Before  tying  the  sutures  the  space 


PROLAPSE   OF   THE  RECTUM 


693 


between  the  rectum  and  sacrum  should  be  freed  from  all  clots  and 
the  oozing  checked.  The  gut  is  thus  anchored  in  close  apposition  with 
the  sacrum,  to  which  it  unites  in  due  time.  The  external  wound  is 
closed  by  buried  catgut  and  subcutaneous  sutures.  If  the  sphincters 
are  much  relaxed  or  overstretched,  a  ligature  of  kangaroo  tendon 
(Fowler)  is  passed  around  the  anus  at  the  upper  margin  of  the  external 
sphincter,  and  tied  over  the  index  finger  introduced  through  the  anus, 
as  has  been  advised  by  Piatt.  This  narrows  the  anal  outlet  and  causes 
contracture  of  the  muscle,  thus  contributing  to  the  cure.  The  bowels 
are  confined  for  eight  days,  when  they  are  moved  by  enemata.  The 
patient  is  required  to  remain  in  bed  and  use  the  bedpan  for  three  weeks, 
after  which  time  he  may  be  allowed  to  go  to  the  toilet.  The  anchoring 
sutures  are  left  in  from  ten  to  fourteen  days. 

Up  to  the  present  writing  the  operation  has  been  employed  by  the 
author  in  10  cases;  3  of  them  have  been  in  old  people,  5  in  people  of 


Fn..  -s-io. — Rectopexy — the  Sutures  out  through  the  Tissues  on  each  Side  of 

THE  Sacrum. 


middle  age,  and  2  in  children.  In  3  of  these  the  procidentia  had  existed 
for  fifteen  and  eighteen  years  respectively.  Seven  of  them  have  re- 
mained cured  from  one  to  three  years.  Three  have  been  done  less  than 
a  year,  but  so  far  there  has  been  no  recurrence.  In  the  case  of  a  woman 
of  thirty-five  years  of  age,  operated  on  through  the  courtesy  of  Dr. 
Lusk,   several  other  methods  had  been  tried,   and   among  them  the 


694 


THE   ANUS,   RECTUM,  AND   PELVIC  COLON 


Dieffenbach-Roberts  operation,  whicb  resulted  in  incontinence  and 
large  cicatrices  at  the  posterior  commissure  of  the  anus,  necessitating 
a  plastic  operation  to  restore  the  sphincter  after  the  prolapse  had  been 
sutured  to  the  sacrum.  It  has  now  been  eighteen  months  since  this 
operation  was  done,  and  beyond  a  slight  prolapse  of  the  mucous  mem- 
brane at  the  anterior  commissure  there  has  been  no  recurrence.  This 
is  certainly  one  of  the  severest  tests  to  which  the  operation  could  be  put. 
The  method  is  only  effectual  in  those  cases  in  which  the  prolapse  is 
confined  to  the  rectum,  and  below  that  portion  which  is  entirely  sur- 
rounded by  peritonannn.     It  would  be  useful,  no   doubt,   in  all  cases 


of  prolapse  of  the  first  or  second  degree  to  whatever  length  they  ex- 
tended, but  it  is  perfectly  clear  that  it  could  not  overcome  a  procidentia 
of  the  third  degree.  For  a  prolapse,  however,  of  5  or  fi  inches,  it  will 
prove  entirely  satisfactory. 

In  complete  prolapsus  of  the  second  and  third  degree,  in  which 
the  upper  portion  of  the  rectum  and  sigmoid  flexure  are  involved, 
there  is  an  entirely  diff'erent  problem  to  solve.  The  anus  and  lower 
end  of  the  rectum  may  be  narrowed  and  thus  obviate  the  protrusion 
of  the  prolapse;  but  this  simply  shuts  out  from  view  the  displaced 
organ,  and  in  no  wise  restores  it  to  position.  Those  conditions  depend 
upon  the  giving  way  of  the  superior  supports  or  upon  an  abnormally 
long  mesenterv,  and  their  treatment  consists  in  a  restoration  of  these 


PROLAPSE  OP  THE  RECTUM  695 

supports  or  the  substitution  of  others  for  them.  The  exciting  cause 
should  be  removed;  if  there  be  stricture  o:f  the  gut,  it  should  be  dilated 
or  resected;  if  neoplasms,  they  should  be  removed;  and  ulcerations 
should  be  healed  if  possible.  The  methods  accomplishing  this  will 
suggest  themselves  to  the  operator  in  individual  cases.  Inasmuch  as 
most  of  these  prolapses  occur  at  the  time  of  stool,  and  are  associated 
with  constipation  and  difaculty  in  defecation,  restoration  of  these  func- 
tions, so  as  to  produce  regular  and  easy  stools,  should  be  always  first 
attempted.  This  may  eradicate  the  cause  and  alleviate  the  suffering, 
but  it  can  not  restore  the  supports  of  the  intestine.  Persistent  re- 
placement of  the  prolapse,  retaining  it  inside  by  adhesive  straps  across 
the  buttocks,  the  movement  of  the  bowels  in  a  reclining  posture,  and 
the  injection  of  astringent  fluids,  may  sometimes  prove  effectual  in 
procidentia  of  the  second  degree  in  children  and  in  people  of  middle 
age;  but  in  old  people  and  in  debilitated  constitutions,  such  methods 
are  not  likely  to  prove  permanently  beneficial. 

In  prolapse  of  the  third  degree  great  relief  to  the  symptoms  may 
be  given  by  persistent,  periodic  introduction  of  long  Wales  bougies, 
by  which  the  gut  is  carried  back  into  position,  and  the  movement  of 
the  bowels  greatly  facilitated.  This  is  only  a  palliative  treatment, 
and  while  the  author  still  recommends  it  as  the  most  conservative  and 
satisfactory  non-operative  method,  he  can  not  say  that  its  effects  are 
at  all  permanent. 

In  view  of  the  fact  that  many  cases  of  prolapses  only  occur  at  the 
time  of  stool,  it  has  been  suggested  that  absolute  physical  rest  of  the 
rectum  would  result  in  the  organ's  resuming  its  normal  position  and 
becoming  fixed  there.  In  order  to  accomplish  this  an  artificial  anus 
must  be  made  and  borne  for  a  sufficient  time  for  these  changes  to 
take  place.  This  method  was  employed  first  by  Jeannel  in  1889,  and 
afterward  by  Bryant  in  1893.  Jeannel's  case,  however,  was  not  a  fair 
demonstration  of  the  principle,  inasmuch  as  he  dragged  the  sigmoid 
and  rectum  from  below  up  into  the  wound  until  the  lower  segment 
was  taut,  and  suturing  it  in  this  position  thus  held  the  gut  up  and  pre- 
vented recurrence  of  the  prolapse.  He  afterward  closed  the  artificial 
anus  without  dissecting  the  gut  loose  from  its  attachment,  and  ob- 
tained a  permanent  cure  of  the  prolapse.  The  result  in  this  case  was 
undoubtedly  due  to  the  adhesion  between  the  gut  and  the  abdominal 
wall.  In  Bryant's  case,  however,  no  effort  was  made  to  drag  the  pro- 
lapse upward.  A  classical  inguinal  anus  was  established,  the  gut  being 
pulled  down  from  above  in  order  to  prevent  its  prolapse  through  the 
artificial  opening.  The  result  in  this  case  was  very  good  at  first,  but 
after  some  months  the  prolapse  began  to  recur,  and  Dr.  Bryant  was 
finally  compelled  to  resort  to  sigmoidopexy  in  order  to  overcome  the 


696  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

prolapse.  Jeannel,  recognizing  the  facts  in  his  case,  suggested  that 
the  results  would  have  been  just  as  good  had  he  simply  sutured  the 
gut  in  the  abdominal  wound  and  made  no  artificial  anus  whatever. 

Acting  upon  this  suggestion,  Verneuil  performed  in  1889  the  first 
typical  colopexy,  as  he  termed  it.  Inasmuch  as  the  sigmoid  was  the 
portion  of  the  intestine  sutured  to  the  abdominal  wall,  it  appears  that 
the  terra  sigmoidopexy  would  be  more  appropriate,  and  we  shall  adopt 
it  in  this  work. 

The  operation  consists  in  drawing  the  sigmoid  and  rectum  upward 
until  the  prolapse  is  entirely  overcome  and  the  lower  end  of  the  intes- 
tinal tract  is  made  comparatively  taut  between  the  anus  and  the  ab- 
dominal wound.  The  sigmoid  is  then  sutured  to  the  abdominal  wall, 
where  it  adheres,  and  thus  prevents  the  recurrence  of  the  prolapse. 
Thus  far  51  cases  (15  of  which  occurred  in  the  author's  practice)  have 
been  collected  in  which  this  procedure  has  been  adopted  with  almost 
uniform  success.  The  technique  of  the  different  operators  varies  con- 
siderably, and  increased  experience  alone  can  determine  which  is  the 
best.  Most  surgeons  advise  suturing  the  gut  to  the  parietal  peri- 
tonaeum. In  one  case  in  which  this  operation  was  done  the  prolapse 
recurred  after  four  months.  The  abdomen  was  then  opened  for  the 
second  time,  and  it  was  found  that  the  adhesive  bands  between  the 
gut  and  parietal  peritonasum  had  stretched  out  to  the  length  of  6 
inches,  thus  demonstrating  the  fact  that  the  adhesion  between  two 
peritoneal  surfaces  was  not  sufficiently  firm  and  inelastic  to  perma- 
nently support  a  large  procidentia  recti.  In  this  case  the  peritonaeum 
was  stripped  off  from  one  side  of  the  abdominal  wound  to  the  extent 
of  about  1  inch,  and  the  gut  sutured  to  the  transversalis  fascia.  The 
result  remained  permanent  for  three  years,  after  which  the  patient 
disappeared  and  has  not  been  heard  from  since.  In  all  subsequent 
operations,  therefore,  the  author  has  sutured  the  gut  to  the  fascia 
instead  of  the  parietal  peritonaeum.  The  technique  employed  is  as  fol- 
lows : 

The  patient  having  been  prepared  for  laparotomy,  an  incision  of 
about  3  inches  is  made  through  the  body  of  the  left  rectus  muscle, 
beginning  2^  inches  above  the  pubis  and  extending  upward  toward 
the  umbilicus.  The  peritoneal  cavity  having  been  opened,  the  patient 
is  placed  in  the  Trendelenburg  posture  and  the  parietal  peritonaeum 
is  stripped  off  from  the  sides  of  the  lower  angle  of  the  abdominal 
wound  to  the  extent  of  about  -J  inch.  The  sigmoid  flexure  is  then 
caught  and  dragged  upward  into  the  wound  until  the  entire  prolapse 
is  overcome  and  the  gut  between  this  point  and  the  anus  is  drawn 
comparatively  taut.  Fine  silk  or  chromicized  catgut  sutures  are  then 
passed   first    through    the    transversalis    fascia   upon    one    side,    then 


PROLAPSE   OF   THE   RECTUM  697 

through  the  longitudinal  muscular  band  of  the  intestine,  and  finally 
through  the  fascia  upon  the  opposite  side.  Three  of  these  sutures 
are  used  to  fasten  the  gut  to  the  fascia  over  a  space  about  1^  inch 
in  length.  The  gut  thus  having  been  anchored,  the  uj^per  angle  of 
the  peritoneal  vound  is  sutured  with  catgut,  and  the  abdominal  walls 
are  closed  by  suturing  the  rectus  muscle  and  its  sheath  with  buried 
kangaroo  tendon,  the  edges  of  the  skin  being  brought  together  by  sub- 
cutaneous or  continuous  silkworm-gut  sutures.  The  wound  is  dressed 
antiseptically,  and  the  patient  is  placed  in  bed,  the  foot  of  which  is 
elevated  about  2  feet.  This  position  is  maintained  for  five  days,  at 
the  end  of  which  time  the  foot  of  the  bed  is  let  down,  and  the  bowels 
are  moved  on  the  seventh  day. 

The  operation  has  been  performed  15  times;  in  7  cases  for  proci- 
dentia, and  in  8  for  adhesions  and  acute  flexure  of  the  sigmoid  upon 
the  rectum.  The  results  have  been  good  in  every  case  with  the  excep- 
tion that  some  patients  complain  of  an  annoying,  dragging  pain  at  the 
side  of  the  adhesion.     In  no  c-ase  has  the  prolapse  recurred. 

Dr.  Mathews  (Jour,  of  Amer.  Med.  Ass'n,  1901,  vol.  i)  has  reported 
a  case  in  which  he  overcame  a  verv  voluminous  procidentia  by  sigmoido- 
pexy.  In  this  case  the  gut  was  sewed  to  the  parietal  peritongeum,  and 
the  adhesions  seem  to  have  been  firm  enough  to  support  it,  as  the  pa- 
tient has  remained  well  since  1899. 

The  method  of  MacCleod,  of  Calcutta  (recommended  by  Allingham 
in  the  sixth  edition  of  his  book),  consists  in  introducing  the  left  hand 
into  the  rectum  and  carrying  it  upward  until  the  finger  becomes  prom- 
inent above  Poupart's  ligament.  A  steel  needle  is  then  passed  through 
the  abdominal  wall,  penetrating  the  cavity  of  the  gut,  and,  guided 
by  the  finger,  is  carried  outward  until  it  emerges  upon  the  abdominal 
wall  about  3  inches  inside  of  the  point  of  entrance.  A  second  needle 
is  then  passed  in  the  same  direction  about  3  inches  above  the  first; 
the  gut  being  thus  temporarilv  fixed,  the  hand  is  withdrawn  and  an 
incision  is  made  in  the  abdominal  wall  between  the  two  needles  and 
at  right  angles  to  them.  A  careful  dissection  is  made  through  this 
incision  until  the  peritonaeum  is  reached.  The  left  hand  is  then  rein- 
troduced into  the  bowel,  and  "  two  series  of  silkworm  sutures  are 
inserted,  four  on  each  side,  at  a  distance  of  about  1  inch  apart,  so  as 
to  attach  the  serous  and  muscular  coats  of  the  intestine  to  the  ab- 
dominal wall.  A  series  of  these  loops  also  penetrating  the  outer  wall 
of  the  intestine  will  pass  between  the  several  points  of  these  rows,  which 
are  made  to  bring  the  lips  of  the  woimd  together,  and  between  them 
small  horsehair  stitches  are  inserted;  antiseptic  precautions  are  em- 
ployed; after  the  operation  a  morphine  suppository  is  introduced  into 
the  bowel,  and  opium  is  given  every  three  hours." 


698  THE  ANUS,  RECTUM,  AND   PELVIC   COLON 

The  wliole  operation  seems  to  be  based  upon  a  fear  of  entering 
the  peritoneal  cavity,  and  yet  that  cavity  is  penetrated  with  a  needle 
■  passed  through  the  skin  and  through  the  cavity  of  the  gut,  not  only 
once  but  four  times.  There  is  not  a  single  step  in  the  whole  procedure 
that  should  not  be  condemned  by  every  scientific  surgeon.  This  promi- 
nence is  given  to  it  simply  because  it  has  been  frequently  quoted  as 
an  example  of  sigmoidopexy.  It  is  a  most  dangerous,  unscientific,  and 
uncalled-for  operation.  The  bibliography  upon  this  subject  has  been 
carefully  covered  in  the  article  of  Bryant  (N.  Y.  Med.  Jour.,  1898,  vol.  i, 
p.  164). 

AVhen  the  procidentia  is  not  due  to  neoplasm  or  organic  stricture 
and  can  be  completely  reduced,  sigmoidopexy  will  usually  result  in  its 
permanent  cure.  If  it  be  a  voluminous  case  of  the  first  degree,  in 
which  the  lower  and  active  supports  of  the  gut  have  given  way,  the 
sigmoidopexy  may  be  supplemented  by  suturing  the  rectum  to  the 
sacrum  after  the  manner  which  has  already  been  described.  When 
the  prolapse  can  not  be  reduced,  or  when  it  is  in  such  a  condition 
of  inflammation  or  gangrene  that  it  is  not  wise  to  do  so,  some  other 
method  of  treatment  must  be  undertaken,  and  in  these  cases  the  removal 
of  the  strangulated  or  diseased  intestine  will  naturally  suggest  itself. 

Excision. — Amputation  of  the  prolapsed  rectum,  while  simple 
enough  in  itself,  may  prove  a  very  serious  operation.  The  chief  danger 
lies  in  the  existence  of  archocele  or  rectal  hernia,  which  necessitates  the 
opening  of  the  peritoneal  cavity  through  the  mucous  membrane  of 
the  gut.  This  condition  will  be  discussed  among  the  complications  of 
prolapsus.  It  is  sufficient  here  to  mention  the  fact  that  in  every  proci- 
dentia of  more  than  2  inches,  one  is  likely  to  meet  with  a  peritoneal 
pouch  in  which  there  may  be  a  hernia  of  the  small  intestine.  Any 
operation  vipon  such  a  prolapse  may  penetrate  this  cul-de-sac  and  bring 
on  peritonitis,  adhesion,  or  strangulation  of  the  gut  contained  in  it. 
Amputation  of  the  prolapse,  where  the  gut  is  perfectly  healthy,  can 
not  be  considered  a  very  dangerous  operation,  but  it  is  certainly  more 
so  than  sigmoidopexy,  and  is  never  necessary  when  the  procidentia 
can  be  reduced.  When  the  tissues  are  so  unhealthy  that  it  is  not  safe 
to  reduce  the  prolapse,  amputation  through  thom  involves  great  danger 
of  septic  peritonitis.  In  a  certain  number  of  cases  where  the  proci- 
dentia is  due  to  organic  stricture,  which  stricture  has  reached  the  lowest 
point  of  the  prolapse,  the  whole  may  be  excised,  and  thus  the  stricture 
and  procidentia  cured  at  the  same  time.  This  has  been  done  l)y  Dr. 
Louis  Ladinski  in  a  case  which  the  author  had  the  opportunity  of  see- 
ing. The  procidentia  extended  7|  inches  outside  of  and  below  the 
anus,  and  the  stricture  at  its  lowest  end  would  barely  admit  the  little 
finger  (Fig.  167).     The  whole  mass  was  amputated,  the  edges  of  the 


PEOLAPSE   OF   THE  RECTUM  699 

gut  being  sutured  together,  and  a  most  happy  result  obtained.  Where 
large  areas  of  the  sigmoid  and  colon  protrude  through  the  anus,  amputa- 
tion may  be  successful,  but  it  should  not  be  employed  if  the  gut  is 
healthy  and  can  be  reduced,  for  under  such  circumstances  the  intestine 
may  be  sutured  to  its  normal  position  with  less  danger  than  is  involved 
in  amputation. 

In  amputating  a  prolapse  of  the  second  degree  involving  the  sig- 
moid flexure,  the  point  at  which  the  union  of  the  two  segments  is 
made  will  be  retracted,  and  it  is  very  likely  to  leak  and  cause  infection  of 
the  peritoneal  cavity.  The  conditions  which  seem  to  justify  anipu- 
tation  are:  the  existence  of  neoplasms  involving  the  entire  thickness 
of  the  gut  wall,  organic  strictures,  gangrene  or  sloughing  of  the  pro- 
truded gut,  and  adhesions  such  as  prevent  reduction. 

Numerous  methods  of  performing  this  operation  have  been  devised. 
Those  advocated  by  Treves,  Lange,  Kleberg,  Mikulicz,  and  Fowler  have 
been  most  frequently  employed.  Only  the  last  two  methods  will  be 
described,  as  they  seem  to  possess  all  the  advantageous  features  of 
the  others. 

Mikulicz's  Method. — The  technique  as  here  described  differs  slightly 
from  that .  originally  laid  down  by  Mikulicz  (Deutsch.  Gesellsch.  f . 
C'hir.,  Bd.  xvii).  The  patient  having  been  previously  antiseptically  pre- 
pared and  anaesthetized,  is  placed  in  the  lithotomy  position  with  the 
hips  well  elevated.  The  prolapse  is  then  dragged  down  as  far  as  possi- 
ble by  traction  forceps.  It  is  then  clamped  by  two  volsella  forceps 
and  held  in  this  position  by  assistants.  The  elevated  position  of  the 
hips  allows  any  coils  of  small  intestine  to  slip  out  of  the  peritoneal 
pouch,  and  thus  avoids  the  danger  of  wounding  them.  i\.fter  the  intes- 
tine has  been  dragged  down,  it  should  be  surgically  cleansed  and  dried 
by  sterilized  gauze.  A  sterilized  conical  sponge  should  be  carried  up 
through  the  gut  in  order  to  avoid,  as  far  as  possible,  any  contents  of 
the  bowels  coming  down  upon  the  field  of  operation.  After  these 
preparations,  an  incision  is  made  through  the  mucous  membrane  upon 
the  anterior  surface  of  the  gut  at  the  margin  of  the  anus.  Dissection 
is  carefully  carried  through  the  entire  thickness  of  the  intestine,  all 
bleeding  being  checked  as  it  occurs,  until  the  peritoneal  cavity  is 
opened.  When  this  has  been  done,  the  serous  membrane  of  the  intus- 
suscepted  portion  of  the  gut  will  be  brought  into  view.  This  mem- 
brane should  be  cut  through,  and  its  upper  edge  sutured  to  the  peri- 
toneal edge  of  the  wound  in  the  anterior  layer  of  the  prolapse.  Thus, 
step  by  step,  the  peritoneal  pouch  is  closed.  This  having  been  accom- 
plished, the  entire  thickness  of  the  intussuscepted  gut  is  then  cut 
through,  little  by  little,  and  its  muscular  and  mucous  layers  are  sutured 
by  interrupted  silk  or  chromicized  catgut  to  the  mucous  membrane 


700  THE   ANUS,  KECTUM,  AND   PELVIC  COLON 

surrounding  the  margin  of  the  anus  at  the  site  of  tlie  original  incision. 
In  this  manner  the  entire  prolapse  is  excised,  and  end-to-end  union  of 
the  gut  is  accomplished.  The  ends  of  the  sutures  in  the  muscular  and 
mucous  layers  should  be  left  long  in  order  to  steady  the  parts  and 
prevent  their  retraction  while  the  operation  upon  the  other  portion  of 
the  circumference  is  being  made.  All  bleeding  points  should  be  caught 
and  twisted  or  ligated  during  the  operation.  After  completing  the 
excision,  if  the  edges  of  the  mucous  membrane  are  not  in  accurate 
apposition  a  tine  running  suture  of  catgut  should  be  applied  around 
the  entire  circumference  to  accomplish  this.  The  long  ends  of  the 
sutures  should  then  be  cut  off,  the  wound  dusted  with  iodoform  or 
boric  acid,  and  over  this  several  layers  of  flexible  collodion  should 
be  applied.  The  sponge  should  then  be  removed,  a  good-sized  drainage- 
tube  introduced  into  the  rectum,  and  the  parts  dressed  around  it  with 
sterilized  gauze.  The  bowels  should  be  confined  for  seven  or  eight 
days,  and  opium  should  be  freely  administered  to  quiet  peristaltic  ac- 
tion. The  advantages  of  this  operation  consist  chiefly  in  the  careful 
opening  of  the  peritoneal  cavity,  and  emptying  it  of  any  prolapsed  loops 
of  small  intestine  or  omentum,  thus  obviating  the  dangers  of  cutting 
or  puncturing  them,  as  exists  in  both  the  Treves  and  Kleberg 
operations. 

George  B.  Fotrler's  Method. — In  this  operation  a  row  of  fenestrated 
forceps  or  common  artery  clamps  is  placed  Just  in  front  of  the  juncture 
of  the  mucous  membrane  with  the  skin  of  the  anus  in  such  a  manner 
as  to  pinch  up  a  circular  fold  from  the  outer  cylinder  of  the  prolapse 
for  the  entire  circumference  of  the  gut.  Half  an  inch  in  front  of 
this  fold  an  incision  is  made  through  the  mucous  membrane  only,  ex- 
tending entirely  around  the  prolapse.  The  proximal  edge  is  then  dis- 
sected back  for  half  an  incli.  Two  clamps  are  then  placed,  one  on  either 
side,  at  the  lower  end  of  the  prolapse,  or  the  place  where  the  outer 
cylinder  of  the  gut  returns  to  form  the  inner  cylinder,  by  means  of 
which  the  mass  is  steadied.  The  index  finger  of  the  left  hand  is  then 
passed  into  the  inner  cylinder,  and,  with  this  as  a  guide,  the  circular 
incision  already  made  is  deepened  so  as  to  include  the  entire  walls  of 
the  two  cylinders.  This  incision  is  about  -J  inch  long.  A  suture  of 
catgut  is  now  passed  so  as  to  include  the  entire  thickness  of  the  two 
cylinders  at  the  point  of  this  incision,  with  the  exception  of  the  mucous 
membrane  of  the  outer  cylinder  which  has  been  turned  back  at  the 
anal  margin.  This  step  of  the  operation  is  repeated  until  the  entire 
circumference  of  the  prolapse  is  traversed,  save  that  the  subsequent 
sutures  are  first  introduced  before  the  incision  is  extended.  Fowler 
states  that  when  the  ])osterior  portion  of  the  circumference  is  reached 
and  the  mesenteric  attachment  of  the  gut  encountered,  no  difficulty 


PROLAPSE   OF   THE   RECTUM  701 

is  met  in  securing  tlie  Ijloocl-vessels  of  the  mesentery  in  the  suture. 
He  treats  this  portion  exactly  as  the  anterior  i3ortion.  After  the  pro- 
lapse has  been  amputated,  the  cuff  of  mucous  membrane  which  was 
dissected  back  at  the  beginning  of  the  operation  is  replaced  and  sutured 
in  position  over  the  first  row  of  sutures.  The  operation  is  performed 
under  a  continuous  stream  of  borosalicylic  solution,  the  parts  are 
dressed  with  a  light  tampon  of  zinc-oxide  gauze,  and  the  bowels  moved 
on  the  third  day. 

He  states  that  the  culf  of  mucous  membrane  which  is  dissected  back 
in  the  first  step  of  the  operation .  preserves  the  normal  conditions  at 
the  anal  outlet,  and  also  provides  a  covering  for  the  sutured  edges  of  the 
stump,  thus  diminishing  the  dangers  of  subsequent  infection  (Med. 
News,  1900,  vol.  Ixxvii,  p.  879). 

In  the  second  degree  of  procidentia  it  will  be  seen  from  the  illus- 
tration (Fig.  223)  that  amputation  will  accomplish  the  removal  of  only 
a  part  of  the  prolapsed  gut.  It  is  questionable  whether  the  operation 
will  result  in  the  retraction  and  cure  of  the  entire  prolapse.  There  is 
little  question  that  it  will  do  so  in  those  cases  in  which  the  procidentia 
is  due  to  a  stricture  or  neoplasm,  this  being  removed  by  the  amputa- 
tion. But  where  the  procidentia  is  due  to  simple  inflammatory  causes, 
with  hypertrophy  and  thickening  of  the  intestinal  wall,  it  is  very  prob- 
able that  the  cure  will  not  be  complete. 

Several  cases  of  stricture  resulting  from  amputation  have  been 
reported,  but  no  satisfactory  observations  have  been  made  as  to  the 
final  results  of  amputating  large  areas  of  the  bowel  for  ^Drolapsus. 
The  large  intestine  is  one  of  the  chief  absorptive  organs  of  the  body, 
and  amputation  of  any  considerable  portion  of  it  may  seriously  inter- 
fere with  the  nourishment  of  the  patient.  This  fact  should  always 
be  considered  where  the  operation  of  excision  is  contemplated.  The 
amputation  of  rectal  prolapses  has  been  remarkably  free  from  fatal 
results,  considering  the  magnitude  of  the  operation.  Only  three  deaths 
have  been  reported  from  this  cause,  while  a  large  number  have  oc- 
curred from  the  so-called  conservative  or  proctoplastic  operations. 
Thus  far  no  deaths  have  occurred  from  colopexy  or  signioidopexy: 
therefore,  where  the  latter  operation  is  feasible,  it  should  be  the  method 
of  election.  Amputation  should  be  considered  a  method  of  necessity 
and  not  of  choice. 

Complications  of  Prolapse. — The  different  forms  of  procidentia  are 
not  onlv  complicated  at  times  by  the  existence  of  neoplasms  which  have 
been  described  as  etiological  factors,  but  also  by  inflammatory  condi- 
tions, ulcerations,  strangulation,  archocele,  and  rupture  of  the  rectal 
wall.  The  inflammatory  conditions  are  found  in  cases  brought  on  by 
acute  inflammatorv  diseases  of  the  rectum,  such  as  dysentery,  summer 


702  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

diarrha'ci,  or  infectious  proctitis  in  cliihlrcn.  They  are  also  found  in 
old  cases  of  extensive  procidentia  in  which  the  gut  remains  down  much 
of  the  time  and  suffers  from  friction  b}'  the  clothing  or  the  opposing 
buttocks.  In  the  first  class  of  cases  the  intlammation  is  a  cause  rather 
than  the  result  of  the  disease,  and  the  subduing  of  it  will  finally  end 
in  the  restoration  and  cure  of  the  prolapse.  In  these  cases  the  bowels 
should  be  sponged  off  with  a  warm  solution  of  hamamelis  or  fluid  extract 
of  hydrastis,  a  little  of  the  solution  being  injected  well  up  into  the 
intestine.  The  prolapse  should  then  be  restored  and  held  in  position 
by  a  properly  fitting  compress,  the  patient  being  kept  upon  the  back. 
Suthcient  opiates  should  be  administered  to  control  the  peristaltic  ac- 
tion, and  a  liquid,  concentrated  diet  should  be  given. 

In  the  second  class  of  cases,  inflammations,  ha-morrhages,  erosions, 
and  idcerations  are  due  to  mechanical  irritations  and  interference  with 
the  circulation. 

The  h;emon'hages  are  best  checked  by  applications  of  cocaine  or 
suprarenal  extract.  The  application  of  cold  for  this  purpose  is  unad- 
visable,  inasmuch  as  it  is  very  liable  to  be  followed  by  sloughing  of 
the  parts.  The  use  of  persul})hate  of  iron  is  objectionable,  because  it 
forms  a  hard  clot  and  irritates  the  intestine.  The  fluid  extract  of 
hydrastis  ayiplied  in  a  ."iO-per-cent  solution  contracts  the  blood-vessels, 
and  will  prevent  the  recurrence  of  haemorrhages  for  some  time.  Where 
the  surface  is  eroded,  a  mild  solution  of  nitrate  of  silver  or  a  2-per-cent 
solution  of  ichthyol  in  oil,  jiainted  all  over  it,  will  form  a  sort  of  pro- 
tective coat  and  give  much  relief.  Where  the  ulcers  are  well  defined 
and  isolated,  a  20-to-50-per-cent  solution  will  be  of  benefit  to  stimulate 
healthy  granulation  and  hasten  the  cure. 

None  of  these  remedies,  however,  will  be  permanently  useful  unless 
the  patient  is  kept  in  bed  and  the  prolapse  retained  inside  of  the  anus. 
The  interference  with  the  circulation  caused  by  the  constriction  of 
the  sphincter  and  the  oedema  of  the  parts  militates  against  the  heal- 
ing of  the  erosions  and  ulcerations.  Firm  compresses  kept  upon  the 
anus  will  sometimes  ])revent  the  prola])se  from  coming  down;  at  other 
times  strapping  the  buttocks  together  by  adhesive  straps  is  more 
effectual. 

The  author  has  never  seen  any  good  come  from  rectal  plugs  which 
pass  up  through  the  anus.  They  increase  the  relaxation  of  the 
sphincter  muscles,  and  simply  add  to  the  difficulty  which  they  are 
intended  to  cure. 

Strangulation  is  a  very  rare  complication  of  procidentia.  The 
instances  which  have  been  reported  have  occurred  chiefly  in  traumatic 
cases  in  which  the  procidentia  was  brought  on  very  suddenly  by  acci- 
dent or  injury.     Ordinarily  the  procidentia  coming  on  and  increasing 


PROLAPSE   OP  THE  RECTUM  703 

gradually,  dilates  the  sphincter,  overcomes  its  spasmodic  tendency,  and 
therefore  the  latter  does  not  produce  any  constriction.  This  is  true 
in  children  as  well  as  in  elderly  patients.  Occasionally,  however,  acute 
inflammatory  conditions  set  up  in  the  protruded  gut,  causing  an  unusual 
oedema  and  swelling,  and  thus  the  prolapse  is  constricted  not  through 
any  spasm  of  the  muscle,  but  through  the  processes  going  on  in  itself. 
Under  such  circumstances  the  entire  mucous  membrane  may  slough 
off,  or  the  gut  itself  may  become  gangrenous.  The  reduction  of  the 
prolapse  under  such  circumstances  is  a  difficult  procedure,  and,  more- 
over, it  is  exceedingly  doubtful  whether  it  should  be  attempted.  If  it 
were  certain  that  the  mucous  membrane  alone  were  involved  in  the 
gangrenous  processes,  it  might  be  perfectly  safe  to  reduce  the  prolapse. 
But  if  the  submucous  and  muscular  walls  are  involved,  they  will  be  so 
weakened  that  manipulation  at  reduction  may  result  in  rupture;  or  even 
if  reduction  is  accomplished  without  this  accident,  the  gangrenous 
processes  may  extend  into  the  peritoneal  cavity  and  thus  cause  fatal 
peritonitis.  The  author  is  of  the  opinion  that  immediate  excision  of 
the  gangrenous  gut  is  a  safer  procedure  in  such  cases  than  attempts  at 
reduction.  Where  the  case  is  seen  before  sloughing  takes  place,  efforts 
at  reduction  should  be  made  according  to  the  methods  heretofore 
described. 

Age  is  sometimes  spoken  of  as  a  complication  contraindicating  at- 
tempts at  permanent  cure  of  procidentia.  Old  people  cling  to  life  as 
tenaciously  as  the  youthful,  and  whatever  worries,  irritates,  or  dis- 
tresses them  shortens  their  days.  The  author  has  reported  elsewhere 
a  large  series  of  operations  upon  patients  above  sixty  years  of  age, 
and  has  shown  conclusively  that  in  the  absence  of  marked  organic  dis- 
ease these  individuals  stand  aseptic  surgical  operations  quite  as  well 
as  those  of  forty  years  (Jour,  of  the  Amer.  Med.  Ass'n,  vol.  i,  1901).  The 
radical  cure  of  procidentia,  therefore,  should  be  undertaken  in  this 
class  of  patients  whenever  the  circumstances  call  for  it. 

Another  complication  is  that  in  which  excessively  large  areas  of 
intestine  prolapse  through  the  anus.  Instances  have  been  reported  in 
which  almost  the  entire  colon  and  6  inches  of  the  ileum  were  pro- 
truded. Cumson  records  the  case  of  a  child  in  which  the  procidentia 
extended  down  below  the  popliteal  space,  and  Esmarch  a  case  in  which 
the  entire  large  intestine,  including  the  ccecum,  protruded  through  the 
anus. 

The  treatment  of  these  extensive  procidentias  or  invaginations  is 
very  difficult.  They  may  sometimes  slough  off  at  the  point  where  the 
upper  portion  of  the  gut  enters  into  the  lower  and  thus  be  cured  spon- 
taneously. A  specimen  in  the  author's  possession  shows  a  portion  of 
the  gut  wdiich  came  away  in  this  manner  after  an  extensive  procidentia; 


704  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

it  was  from  a  patient  of  Dr.  Thomas^,  of  Georgia.  Sixteen  inches  of 
the  gut  came  away. 

Peacock  (Path.  Transactions,  vol.  xv,  p.  113)  reports  a  case  in  which 
it  is  believed  that  40  inches  of  the  intestine  came  away  piece  by  piece, 
and  yet  the  patient  recovered.  Such  a  result,  however,  can  not  be 
relied  upon,  as  85  per  cent  of  the  cases  which  have  pursued  this  course 
have  proved  fatal.  Reduction  of  these  extensive  procidentia,  even 
when  seen  in  their  early  stages,  is  rarely  possible  from  the  outside. 
Nevertheless,  it  should  be  attempted  by  gentle  taxis  and  suspending  the 
patient  in  the  knee-chest  posture.  The  author  has  been  able  to  reduce 
1  case,  in  which  the  procidentia  exceeded  1-1  inches,  after  suspending 
the  patient  in  this  position  for  over  two  hours.  In  fact,  the  procidentia 
was  reduced  spontaneously,  it  being  supported  and  covered  with  warm 
cloths  during  this  period.  Such  resiilts,  however,  can  not  be  ex- 
pected with  any  confidence.  Prolonged  and  violent  taxis  is  likely  to 
inflame  the  gut  and  increase  its  swelling,  or  it  may  result  in  rupture. 
The  question  therefore  arises.  Shall  the  procidentia  be  amputated,  or 
shall  a  laparotomy  lie  done  and  reduction  accomplished  through  the 
peritoneal  cavity  ? 

Where  the  condition  is  seen  before  sloughing  and  gangrene  take 
place,  the  latter  course  is  without  doubt  the  proper  one.  Under  such 
circumstances  amputation  not  only  involves  a  danger  in  itself,  but  also 
that  which  would  follow  upon  the  removal  of  so  large  a  portion  of  the 
digestive  tract.  It  appears  to  the  author,  therefore,  tliat  this  opera- 
tion ought  never  to  be  resorted  to  under  such  circumstances  until 
efforts  at  abdominal  fixation  of  the  gut  have  been  made. 

Lambotte  (La  presse  med..  Beige,  1S9G,  p.  2-i)  has  demonstrated 
the  possibility  of  fixing  these  intussuscepted  guts  in  their  normal  posi- 
tion. In  a  child  in  whom  the  small  intestine  prolapsed  through  the 
cfecum  for  at  least  15  centimeters  (about  6  inches),  and  the  colon  and 
sigmoid  prolapsed  through  the  rectum,  he  made  an  abdominal  incision, 
reduced  the  intussusceptions,  and  suti;red  the  colon  in  its  proper  posi- 
tion at  the  hepatic  and  splenic  flexures,  fastening  the  small  intestine 
along  the  border  of  the  ascending  colon  so  as  to  shorten  its  mesentery, 
and  thus  prevented  the  recurrence  of  the  prolapses.  Three  months 
after  this  operation  the  patient  was  seen  and  was  perfectly  well.  Such 
an  operation  as  this,  or  suturing  of  the  colon  to  the  abdominal  wall, 
should  be  attempted  in  these  cases  of  extensive  procidentia.  It  is  less 
dangerous,  and  the  probable  results  are  certainly  as  promising  as  the 
excision  of  large  areas  of  the  intestinal  canal. 

"\\'Tiere  gangrene  has  already  begun,  cutting  away  the  diseased  and 
protruding  portion  may  be  advisable,  and  may  possibly  save  the  patient 
from  septic  infection.     It  is  evident,  however,  that  the  entire  proci- 


PROLAPSE   OF  THE  RECTUM  705 

dentia  can  not  be  removed  by  this  method  except  in  cases  of  the  first 
degree,  and  the  extensive  invaginations  are  rarely  of  this  variety. 
Operations  through  the  abdomen  and  peritoneal  cavity  after  gangrene 
has  occurred  are  not  advisable. 

Archocele  or  rectal  hernia  is  one  of  the  most  frequent  and  serious 
complications  of  complete  prolapse.  Ludlow  has  attempted  to  show 
that  the  majority  of  prolapses  of  the  rectum  are  due  to  rectal  hernia; 
that  the  cul-de-sac  of  Douglas,  being  low  down  and  pointed  backward, 
causes  an  infundibulum  into  which  the  small  intestines  gra.vitate,  and 
through  abdominal  pressure  sink  lower  and  lower  until  the  gut  is 
invaginated  and  procidentia  is  produced.  This  doctrine  has  not  been 
established  by  clinical  observations,  but  every  careful  observer  must 
have  seen  cases  in  which  this  cul-de-sac  bulged  backward  into  the  rectal 
ampulla  when  the  patient  sits  and  strains,  almost  occluding  this  cavity, 
and  interfering  with  the  fsecal  movements  (Fig.  226).  Sometimes  in 
such  eases  it  is  necessary  for  the  patient  to  pass  his  finger  through 
the  anus  and  press  forward  the  bulging  mass  before  a  satisfactory  evacu- 
ation can  be  obtained.  With  such  cases  in  view,  one  can  not  positively 
deny  the  possible  truth  of  Ludlow's  theory. 

Kelsey  {op.  cit.,  p.  255)  says:  "In  the  external  form  the  sac  is  first 
formed  and  remains  ready  at  any  time  for  the  reception  of  its  con- 
tents," thus  indicating  his  belief  that  the  hernia  has  nothing  to  do 
with  the  production  of  the  procidentia.  This,  however,  can  not  be 
proved  or  disproved.  The  fact  that  rectal  hernise  protrude  into  the 
ampulla  without  appearing  outside  of  the  anus,  certainly  indicates  the 
possibility  that  they  may  gradually  increase  just  as  do  scrotal  hernije, 
overcome  the  resistance  of  the  external  sphincter,  and  finally  cause  a 
procidentia  of  the  gut.  The  extent  of  the  circumference  of  the  pro- 
lapse which  is  involved  by  the  hernial  sac  will  be  determined  by  the 
length  of  th :  prolapse. 

The  existence  of  hernial  sacs,  however,  in  all  cases  of  prolapse 
protruding  more  than  2  inches  through  the  anus  is  undeniable.  The 
farther  the  procidentia  protrudes,  the  larger  \n\\  be  the  sac,  and  the 
more  of  the  intestinal  circumference  will  it  involve.  In  limited  proci- 
dentia the  hernial  sac  is  restricted  to  the  anterior  quadrants,  but  in 
extensive  ones  it  may  involve  the  entire  circumference  with  the  ex- 
ception of  that  part  occupied  by  the  mesentery.  Hernia  of  this  type 
resemble  those  of  the  inguinal  region,  inasmuch  as  they  come  down 
upon  walking  or  straining,  are  reduced  by  pressure  or  position,  may 
become  adherent  to  the  sac,  or  may  be  strangulated  either  through 
spasm  of  the  sphincter  or  contraction  of  the  hernial  neck. 

The  diagnosis  of  hernia  in  procidentia  may  be  made  from  the  thick- 
ness of  the  walls  of  the  procidentia,  the  gurgling  sound  upon  redue- 
45 


706 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


tiou,  the  tympanitic  note  upon  percussion,  dragging  and  griping  sensa- 
tions in  the  abdomen  when  the  hernia  is  down,  and  the  fact  that  the 
aperture  in  the  prohipse  points  either  forward  or  straight  downward 
from  the  anus.  The  importance  of  recognizing  this  condition  in  the 
treatment  of  procidentia  can  not  be  overestimated,  for  too  vigorous 
manipuhition  may  injure  the  intestines,  and  in  the  operation  of  amputa- 
tion the  gut  might  be  wounded  unless  precautions  were  taken  to  reduce 
it  beforehand.  It  is  for  the  purpose  of  reducing  the  hernia  that  the 
Trendelenbvirg  posture  is  advised  in  the  operations  of  Mikulicz  and 
Fowler. 

The  contents  of  these  hernial  sacs  are  variable.  Ordinarily  they 
contain  the  small  intestine,  the  sigmoid,  or  omentum.  Cases,  how- 
ever, have  been  reported  in  which  they  contained  ovaries  and  tubes, 
the  uterus,  the  bladder,  and  the  vermiform  appendix.  All  these  organs 
may  become  adherent  to  the  sac,  and  thus  obviate  reduction.  The  pro- 
lapse itself  may  be  pushed  inside  of  the  anus,  but  the  hernia  will  still 
be  unreduced.     Brunn  (Casper's  Wochenschrift  f.  d.  gesammte  Heil- 


FiG.  235. — Kectal  Hernia  protruding  through  Anus. 


kunde,  1883,  Bd.  ii,  No.  40,  S.  934)  and  Pockels  (Catalog.  Day's  Col- 
legium Anatomical  Chirurg.,  Braunschweig,  1854)  have  reported  inter- 
esting cases  of  this  kind. 

A  very  unusual  type  of  rectal  hernia  is  shown  in  the  illustration 
(Fig.  23.5).  It  was  in  the  person  of  an  old  woman  in  the  Almshouse 
Hospital,  and  was  supposed  to  be  a  case  of  simple  rectocele  when  first 


PROLAPSE  OF  THE   RECTUM 


707 


observed.  Careful  examination  of  the  tumor,  however,  showed  it  to  be 
a  hernial  sac.  When  the  woman  strained  to  move  her  bowels  the  tumor 
would  appear,  sometimes  through  the  anus  and  sometimes  through  the 
vagina  (Fig.  236).    The  photograph  of  the  tumor  prolapsing  through  the 


Fig.  236. — Kectal  Herxia,  sahe  Case  as  Fi&.  285,  proteudixg  through  Vagina. 

anus  was  obtained  by  pressure  upon  the  posterior  vaginal  wall  while  the 
patient  strained  as  if  to  move  the  bowels.  The  patient  died,  and  an 
autopsy  was  not  permitted  by  her  friends,  so  it  is  impossible  to  state 
exactly  what  portion  of  the  intestine  was  included  in  the  hernial  sac; 
but  the  gurgling  sound  upon  reduction,  the  tympanitic  note,  and  the 
fact  that  the  tumor  entirely  disappeared  when  the  patient  was  placed 
in  the  knee-chest  posture,  left  no  doubt  as  to  the  nature  of  the  pro- 
trusion. 

The  chief  danger  from  these  hernias  is  strangulation  and  rupture 
of  the  intestinal  wall.  Strangulation  may  occur  from  constriction  by 
the  sphincter,  the  levator  ani,  or  finally  by  the  longitudinal  muscular 
fibers  of  the  gut  wall  itself.  Sometimes  these  fibers  separate,  allow- 
ing the  hernia  to  protrude  between  them,  the  sac  being  thus  composed 
of  onlv  the  mucous,  submucous,  and  serous  tissues.  The  spasmodic 
contraction  of  the  longitudinal  fibers,  therefore,  may  cause  constric- 
tion of  the  neck  of  the  sac  and  strangulation  of  the  hernia.  Strangula- 
tion from  spasm  of  the  sphincter  is  exceedingly  rare,  and  only  occurs 
when  unusual  amounts  of  intestine  prolapse  into  the  hernial  sac  and 
become  distended  with  gas,  or  when  the  procidentia  becomes  inflamed, 


70S  THE  ANUS,  RECTCM,  AND   PELVIC  COLON 

cedematuvis,  and  thus  unnaturally  enlarged.  It  is  thus  a  question  of 
the  procidentia  becoming  too  large  for  the  anal  aperture  rather  than 
one  of  spasm  of  the  sphinctel*. 

The  treatment  of  such  cases  consists  in  reduction  of  the  hernia,  if 
possible,  by  gentle  taxis  under  the  influence  of  general  anesthesia  or 
large  doses  of  morphine.  Some  surgeons  prefer  the  latter,  holding  that 
it  will  cause  less  nausea  afterward,  which  would  tend  to  the  reproduc- 
tion of  the  hernia.  The  sphincters  should  be  stretched,  or,  if  neces- 
sar}',  incised,  and  one  should  always  remember  that  reduction  of  the 
procidentia  does  not  mean  complete  reduction  of  the  hernia.  After  the 
procidentia  has  been  carried  upward,  a  hand  should  be  introduced  into 
the  rectum  and  the  parts  thoroughly  examined  to  see  that  no  hernial 
sac  containing  strangulated  intestine  protrudes  into  the  rectal  ampulla. 
Where  such  means  fail  to  reduce  the  hernia,  laparotomy  should  be  per- 
formed at  once,  the  contracting  bands  severed  or  dilated,  and  the  hernia 
reduced  by  the  intraperitoneal  route.  Incisions  through  the  rectal 
wall  under  such  circumstances  are  fraught  with  the  greatest  danger. 
The  intraperitoneal  route  is  not  only  less  dangerous,  but  it  affords 
the  opportunity  for  resection  of  the  gangrenous  loops  of  intestine  and 
the  breaking  up  of  any  adhesions  which  may  have  caused  the  incarcera- 
tion of  the  gut.  It  also  has  the  further  advantages  that  the  hernial 
sac  can  be  obliterated  from  this  side  by  accurate  suturing,  and  the 
procidentia  can  be  overcome  by  abdominal  fixation  of  the  sigmoid 
flexure. 

Rupture  of  the  Hernial  Sac. — Aside  from  inflammation,  incarcera- 
tion, and  strangulation,  cases  of  rectal  hernia  may  be  complicated  by 
rupture  of  the  sac  through  the  rectal  wall.  This  may  occur  whether 
the  hernia  protrudes  through  the  anus  or  whether  it  is  confined  to  the 
rectal  ampulla.  Kelsey  (Diseases  of  the  Eectum,  4th  ed.,  p.  240)  gives 
a  most  interesting  collection  of  cases  of  this  kind.  To  those  interested 
in  the  detailed  cases,  this  resume  will  prove  most  interesting. 

The  rupture  may  occur  spontaneously,  as  has  been  described  l)y 
Quenu  (Eevue  de  chirur.,  March  10,  1882),  through  injury,  as  in 
Brunn's  case,  or  through  efforts  at  reduction  of  the  prolapse  and  hernia. 
In  the  case  of  Smith  it  occurred  during  his  efforts  to  cure  the  pro- 
lapse by  taking  away  longitudinal  strips  of  mucous  membrane  with  the 
clamp  and  cautery.  After  the  strip  had  been  removed,  the  patient 
began  to  vomit,  and  the  straining  upon  the  parts  resulted  in  a  rupture 
with  protrusion  of  the  hernial  contents. 

Spontaneous  rupture  due  to  straining  while  at  stool,  vomiting,  or 
lifting  heavy  weights,  is  the  ordinary  course  of  events.  If  the  prolapse 
is  down,  the  small  intestine  or  other  contents  of  the  hernial  sac  will 
protrude  from  the  body  itself.     If  the  rupture  occurs  when  there  is 


PROLAPSE   OF   THE  RECTUM  T09 

no  prolapse  or  protrusion  outside  of  the  anus,  the  gut  may  prolapse 
through  the  wound  into  the  rectal  ampulla  until  this  cavity  is  entirely 
filled.  In  either  case  the  appearance  of  the  small  intestine  or  sigmoid 
with  their  serous  coverings  will  make  the  diagnosis  clear.  The  symp- 
toms of  such  a  condition  are  sudden,  acute  pain  followed  by  collapse, 
shock,  and  protrusion  of  the  gut  either  into  the  rectal  ampulla  or  outside 
of  the  body. 

It  requires  no  elaborate  discussion  of  the  pathology  of  the  condi- 
tions to  account  for  such  ruptures.  Whatever  weakens  the  wall  of  the 
intestine  will  predispose  to  it.  Inflammation,  erosion,  ulceration,  fatty 
degeneration,  varicosity,  and  other  pathological  changes  of  the  intes- 
tinal wall  which  are  likely  to  occur  during  the  course  of  protracted 
procidentise,  will  easily  account  for  the  weakening  of  the  hernial  sac 
and  its  giving  way  under  any  extraordinary  strain. 

Where  rupture  occurs  while  the  prolapse  is  outside  of  the  anus, 
it  has  been  found  that  the  prolapse  itself  will  be  spontaneously  reduced. 
This  fact  indicates  that  the  hernia  has  something  to  do  with  bringing 
down  and  maintaining  the  procidentia.  The  rent  is  variable  in  the 
different  coats  of  the  rectal  walls,  generally  being  longer  in  the  serous 
than  in  the  muscular  coats,  and  least  of  all  in  the  mucous  membrane. 
In  the  cases  of  Englisch  there  was  marked  extravasation  of  blood  be- 
tween the  mucous  and  muscular  coats,  and  between  the  muscular  and 
serous  coats.  In  Smith's  case  the  protruded  gut  was  immediately  re- 
placed, the  rent  sutured,  and  the  patient  made  a  good  recovery.  As 
a  rule,  however,  strangulation  of  the  protruded  gut  occurs  before  opera- 
tive interference  can  be  employed. 

The  mortality  in  such  cases  is  very  high,  but  Smith's  experience 
teaches  that,  if  the  parts  can  be  reduced  at  once,  a  favorable  result 
may  be  obtained. 

The  wonderful  case  of  John  Nedham  (Philosophical  Transactions, 
1755,  vol.  xlix,  p.  238),  quoted  in  full  by  Ivelsey,  is  one  of  those 
unique  accidents  in  surgery  which  it  is  impossible  to  explain.  A  boy 
was  thrown  underneath  a  cart  (turned  upside  down),  and  found  in  this 
position  with  a  very  large  portion  of  his  intestines  forced  through  the 
anus,  a  part  of  the  mesentery  hanging  down  between  the  legs.  He 
was  in  an  intense  condition  of  shock.  After  hot  fomentations  the 
doctor  reduced  the  parts,  but  the  vomiting  immediately  returned  and 
forced  them  out.  On  the  following  day  signs  of  mortification  in  the 
protruded  intestine  appeared,  and  on  the  third  day  the  surgeon  cut 
off  the  intestine,  with  the  mesentery,  close  to  the  anus.  A^ery  shortly 
after  this  operation  there  was  a  discharge  of  black,  offensive,  fffical 
matter,  the  pains  grew  easier,  the  nausea  and  vomiting  ceased,  and  the 
patient  proceeded  to  an  uneventful  recovery.     For  a  while  he  had  six 


710  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

or  seven  stools  daily,  and  had  some  difficulty  in  retaining  them.  The 
doctor  is  not  exactly  certain  as  to  what  point  in  the  circumference 
the  rupture  had  taken  place,  hut  thought  he  felt  an  opening  through 
the  posterior  wall  of  the  rectum  just  ahcve  the  internal  sphincter.  The 
intestine  cut  off  measured  57  inches.  Three  months  afterward  the 
hoy  walked  seven  miles  to  dine  with  the  doctor.  Such  cases  as  this 
are  surgical  curiosities  which  throw  no  light  u}ion  the  etiology  or  treat- 
ment of  the  condition. 

Attempts  at  reducing  the  protruded  gut  in  these  cases  of  rupture 
usually  result  in  crowding  the  small  intestine  up  into  the  rectum  with- 
out restoring  it  to  the  peritoneal  cavity.  Suspending  the  patient  in  an 
exaggerated  knee-chest  posture  may  possibly  cause  the  retraction  of 
the  gut  and  enable  one  to  restore  it  to  its  proper  position.  After 
it  has  become  strangulated  and  gangrenous,  such  a  restoration  would 
not  only  be  useless  but  surgically  dangerous.  If  the  gut  is  much  dis- 
tended with  gases,  large  hypodermic  needles  may  be  inserted  to  allow 
their  escape. 

In  the  gangrenous  cases  it  is  better  to  thoroughly  cleanse  the  parts 
and  incise  the  protruding  mass,  tying  off  the  segments  of  gut  which 
are  left  outside  of  the  anus.  Laparotomy  should  then  be  performed, 
and  end-to-end  union  of  the  healthy  guf  attempted.  The  fortunate 
results  of  JSTedham  should  not  tempt  any  one  to  leave  the  parts  ])ro- 
truding,  as  was  done  in  his  case. 

If  the  gut  is  not  gangrenous,  it  is  the  duty  of  the  surgeon  to  per- 
form laparotomy  at  once  and  reduce  the  procidentia  from  the  peritoneal 
side,  having  washed  off  the  protruding  gut  thoroughly  with  borosalicylic 
solution  before  it  is  withdrawn.  After  the  protruding  gut  has  been 
restored  by  this  method,  the  rent  in  the  rectal  wall  may  be  sutured 
from  the  peritoneal  side,  if  possible;  otherwise  a  gauze  drainage  should 
be  introduced  down  to  the  site  of  the  rupture,  and  the  abdominal  wound 
closed.  A  fa?cal  fistula  may  follow  this  latter  course,  but  it  is  a  matter 
of  small  moment,  as  the  large  majority  of  these  fistulas  heal  spon- 
taneously. 

The  most  important  point  in  connection  with  these  ruptures  is  the 
likelihood  of  their  being  produced  by  unwise  and  too  vigorous  efforts 
at  reduction  of  the  procidentia,  and  by  the  canterizing  or  denuding 
operations  devised  for  their  radical  cure.  The  likelihood  of  such  acci- 
dents should  always  be  borne  in  mind,  and  in  cases  in  which  the  rectal 
wall  is  at  all  diseased,  or  in  which  there  is  evidently  a  hernial  sac  in 
the  prolapse,  such  methods  had  better  be  avoided. 


CHAPTER    XYIII 
BEXKtX  TUJIOBS   of   the  RECTU3I 

The  lower  end  of  the  large  intestine  may  be  tlie  seat  of  a  variety 
of  neoplasms  that  occur  at  the  margin  of  the  ajtius,  in  the  rectum,  or 
in  the  pelvic  colon;  they  are  broadly  classified  as  benign  and  malignant, 
but  it  is  often  a  very  difficult  matter  to  say  just  where  the  one  ends 
and  the  other  begins.  Growths  which  in  themselves  are  not  dangerous 
to  life  may  be  so  gradually  transformed  that  one  finds  both  the  benign 
and  malignant  types  in  the  same  tumor. 

From  a  histological  point  of  view,  tumors  of  the  rectum  may  be 
classified  as  follows: 

The  Cojuiedive-tissue  Type. — Fibroma,  enchondroma,  lymphadeno- 
ma,  lipoma,  m^^xoma,  and  sarcoina. 

TJie  Muscular  Type. — Myoma  and  fibromyoma. 

The  Epithelial  Type. — Adenoma,  papilloma,  and  carcinoma. 

In  addition  to  these  well-defined  types,  teratoma  or  cystoma,  fungi, 
vegetations  and  excrescences  are  met  with. 

Among  the  tumors  of  the  connective-tissue  type  are  sarcoma,  and 
among  those  of  the  epithelial  variety,  carcinoma.  These  growths,  uni- 
versally considered  malignant,  contain  no  histological  elements  not 
found  in  other  growths.  The  peculiar  characteristic  upon  which  their 
malignancy  depends  is  not  understood.  The  fact  that  the  epithelium 
in  one,  and  the  embryonic  cells  in  the  other,  develop  out  of  their  usual 
order  and  location,  will  not  account  for  the  toxic  or  fatal  results  in 
either  case.  Eecent  experiments  with  regard  to  their  bacteriological 
origin  seem  to  point  to  a  possible  solution  of  this  question,  but  so  far 
the  pathologists  have  not  agreed  upon  whether  they  are  the  results  of 
spores,  germs,  parasites,  or  toxins.  At  present  only  those  tumors  will 
be  considered  which,  occurring  in  the  rectum  or  sigmoid,  produce  no 
constitutional  disturbances  beyond  those  due  to  their  mechanical  irri- 
tation and  the  reflex  effects  of  the  same. 

Polypus. — The  term  polypus  or  polyp  is  applied  to  any  pedunculated 
growth.  The  latter  may  be  of  any  histological  variety  so  long  as  it  is 
attached  to  a  surface  of  the  body  by  a  pedicle  narrower  than  the  tumor 

711 


712  THE  ANUS,   RECTUM,  AND   PELVIC   COLON 

itself.  It  is  sometimes  applied  to  sessile,  pyriform,  and  pendulous  neo- 
plasms in  which  there  is  no  pedicle,  but  this  use  of  the  term  is  rapidly 
becoming  obsolete.  When  one  speaks  of  a  polyp  of  the  rectum,  there- 
fore, he  means  a  tumor  attached  to  the  rectal  wall  by  a  pedicle. 

Seat  and  Manner  of  Development. — Polypi  occur  with  greater  or  less 
frequent-}'  throughout  the  intestinal  canal.  Wellbroek,  who  has  searched 
the  literature  on  this  subject,  states  that  in  four-fifths  of  the  cases 
they  are  found  in  the  rectum  and  sigmoid.  It  is  a  question  whether 
this  preponderance  is  not  more  apparent  than  real,  inasmuch  as  this 
portion  of  the  intestine  is  the  only  one  that  can  be  satisfactorily  ex- 
amined during  life,  and  therefore  the  tumors  are  seen  here  when  it 
would  be  impossible  to  observe  them  higher  up. 

Leichtenstern  states  that  about  60  per  cent  occur  in  the  rectum,  25 
per  cent  in  the  ileum,  about  12  per  cent  in  the  colon  and  ileo-ca?cal 
valve,  and  3  per  cent  in  the  small  intestine. 

In  children  they  are  generally  observed  as  isolated  growths,  one,  two, 
or  three  in  number;  most  frequently  there  is  only  one.  In  adults,  how- 
ever, we  find  them  multiple  in  the  majority  of  cases.  Their  seat  is 
ordinarily  about  1  or  2  inches  above  the  margin  of  the  anus,  but  occa- 
sionally they  are  found  much  higher.  Some  have  been  seen  with  pedi- 
cles as  long  as  6  inches  attached  within  the  sigmoid  flexure.  The 
nature  of  the  development  is  explained  as  follows:  A  closed  follicle  or 
gland,  becoming  distended  from  inflammatory  or  other  causes,  protrudes 
into  the  cavity  of  the  recttim,  carrying  the  mucous  membrane  before  it, 
and  sometimes  dragging  a  small  portion  of  the  submucosa  after  it. 
Through  its  weight,  and  the  contraction  of  the  circular  fibers  of  the  gut 
in  Xature's  efforts  to  rid  herself  of  the  enlargement,  the  follicle  is  forced 
do^^^lward,  stretching  the  mucous  membrane,  and  eventually  dragging  it 
out  into  the  shape  of  a  pedicle.  The  irritation  and  hA'peramia  caused 
by  this  sagging,  and  the  obstruction  to  the  return  circulation  from  the 
growth,  bring  about  an  oedema  and  h^^iDertrophy  of  the  follicle  and  its 
surrounding  tissues,  and  thus  the  polypus  is  produced. 

This  method  of  formation  applies  to  all  types  of  polypi,  witli  the 
exception  that  the  original  growth  may  be  a  fibroma,  an  adenoma,  a 
cystoma,  or  a  lipoma  instead  of  a  solitar}-  follicle  or  gland. 

Histological  Types. — The  neoplasms  which  most  frequently  take  on 
this  polypoid  form  are  hypertrophied  solitary  follicles,  adenoma,  fibroma, 
and  lipoma.  The  most  common  form  (that  which  is  generally  found  in 
children)  is  of  the  soft,  mucous  variet}^  probably  originating  in  an 
inflamed  solitary  follicle.  It  consists  of  alveolar  tissue,  the  meshes  of 
which  are  filled  with  a  thick,  viscid  fiuid;  the  surface  is  covered  with 
cylindrical  epithelium,  and  sometimes  it  contains  true  Lieberkiihn 
tubules.     Oceasionallv  the  mucous  srlands  of  the  intestinal  wall   are 


BENIGN  TUMORS   OF  THE  RECTUM 


713 


dragged  into  the  tumor  in  the  processes  of  formation^  and  they  may 
appear  therein  as  small  cysts.  These  glands,  however,  are  accidental, 
and  compose  only  a  very  small  portion  of  the  growth. 

The  specimen  (Fig.  237)  was  taken  from  a  tumor  of  this  type. 

Histological  Examination  Iry  Louis  Heitzmann. — The  tumor  is  composed  of  a 
delicate  fibrous  reticulum,  holding  chiefly  at  its  points  of  intersection  oblong  or 
round  bodies  resembling  nuclei.  In  the  meshes  of  the  network  a  gelatinous,  at 
times  apparently  homogeneous  basis  substance  is  found.  In  the  spaces,  mostly  their 
centers,  lie  single,  double,  or 
multiple  corpuscles  of  vary- 
ing sizes,  the  larger  of  which 
contain  nuclei.  This  tumor 
is  rather  freely  supplied  with 
blood-vessels,  most  of  which 
are  broad  and  lined  with 
large  endothelia,  and  in  their 
neighborhood  the  reticu- 
lum is  narrowest  and  sup- 
plied with  a  larger  number  of 
blood-vessels.  Glandular  for- 
mations are  here  very  scanty. 
Diagnosis :  Soft  rectal  polyp 
or  myxoma  of  reticular  struc- 
ture. 

This  class  of  polyp 
differs  from  the  multiple 
polypi  of  the  rectum  in 
that  it  contains  less 
fibrous  and  glandular 
tissue,  and  more  of  the 
gelatinous  or  myxoma- 
tous material.  They  are 
softer  to  the  touch,  and 
are  rarely  found  except 
in  young  children. 
They  are  more  pedun- 
culated, and  bleed  less 
easily. 

Course  and  Symptoms. 
— The  longer  a  polyp  re- 
mains in  the  rectum,  the 
more  elongated  will  be  the  pedicle;  sometimes  it  passes  outside  of  the 
anus  and  is  grasped  by  the  sphincter  muscle  during  the  act  of  defe- 
cation.    They  may  be  torn  off  and  passed  along  with  the  fsecal  mass, 


Fiu. 


■M 


(Magnified 


A,      EecTAL     PoL-iP. 

diameters.) 
F,  delicate  fibrous  reticulum,  with  nuclei  at  the  points  of 
intersection  enclosing  spaces  which  contain  a  jelly-like 
basis  substance ;  iV,  corpuscles,  mostly  nucleated  in 
the  basis  substance;  L,  lymph  corpuscles;  ^,  artery; 
C,  capillary. 


714  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

a  slight  haemorrhage  resulting,  which  is  rarely  if  ever  serious.  There 
are  frequent  instances  in  which  children  have  thrust  them  out  through 
the  anus,  and  pulled  them  off,  under  the  impression  that  they  were 
foreign  bodies  or  something  adherent  to  the  anus.  So  long  as  they  re- 
main well  up  within  the  rectum  they  do  not  produce  any  marked  symp- 
toms. Patients  are  not  ordinarily  aware  of  their  existence  until  they 
come  down  within  the  grasp  of  the  sphincter  or  rest  upon  the  sensitive 
area  of  the  rectum.  "When  they  prolapse  to  this  extent  they  produce  a 
sensation  of  fulness,  with  frequent  desire  to  defecate,  spasm  of  the 
sphincter,  and  various  reflex  symptoms. 

In  one  case  of  this  kind  which  the  writer  saw  with  Dr.  Lewis,  of 
Jersey  City,  the  woman  suffered  from  constipation,  vague  symptoms 
pointing  to  ovarian  disease,  and  intense  nervous  exhaustion;  the  little 
growi:li  was  removed  by  crushing  the  pedicle  with  a  hemorrhoidal  clamp, 
and  within  a  few  weeks  all  the  symptoms,  except  the  constipation,  dis- 
appeared. 

To  the  eye  these  growths  present  ditt'erent  appearances  according 
to  their  pathological  nature.  The  soft  mucous  polypus  or  myxoma  with 
reticulum,  as  Heitzmann  describes  it,  is  pinkish  or  sometimes  yellowish- 
gray  in  appearance;  at  other  times  it  appears  as  a  raspberry-like  growth 
with  soft,  velvety  surface.  The  lipomatous  polyp  appears  as  a  light- 
yellow  lobulated  mass  covered  by  a  smooth,  shining  mucous  membrane 
which  may  sometimes  be  ulcerated,  but  the  color  of  the  tumor  shows 
through  the  membrane.  The  fibroid  polypus  is  spherical  or  ovoid  in 
shape,  is  not  lobulated,  and  is  covered  either  by  normal  or  bright-red  and 
congested  mucous  membrane  (Plate  Y,  Fig.  3).  Any  of  these  tumors,  if 
protruded  from  the  anus  so  that  the  pedicle  is  constricted,  will  present 
a  dark,  purplish-red  appearance  due  to  the  obstructed  circulation. 

Diagnosis. — The  diagnosis  of  the  existence  of  polypi  is  very  simple; 
they  either  protrude  from  the  anus  and  can  be  seen,  or  by  examination 
with  the  finger  they  may  be  felt  and  recognized.  A  precaution  ordi- 
narily given  in  examinations  with  the  finger  consists  in  the  advice  to 
pass  the  finger  as  far  up  into  the  rectum  as  possible,  and  examine  from 
above  downward  in  order  to  prevent  pushing  the  tumor  upward  before 
it.  Generally  the  tumor  will  be  felt  in  the  ampulla  of  the  rectum  Just 
above  the  sphincter,  and,  if  the  rectum  is  normally  collapsed,  it  may 
be  difficult  to  pass  the  finger  upward  without  carrying  the  tumor  along 
with  it.  This  can  be  avoided  by  sweeping  the  end  of  the  finger  rapidly 
around  the  rectum  so  as  to  excite  muscular  spasm  of  the  circular  fibers, 
which-  will  force  the  tumor  down  while  the  finger  glides  up  alongside 
of  it.  After  the  finger  is  once  above  the  growth,  if  the  pedicle  is  long 
enough  one  can  bring  it  into  view  by  pressing  it  firmly  against  the 
side  of  the  rectum  and  slowly  dragging  it  downward. 


BENIGN  TUMORS  OF  THE  RECTUM  715 

When  polypi  are  above  the  reach  of  the  finger,  or  slip  up  in  front 
of  it,  they  may  be  seen  and  grasped  through  the  proctoscope.  Through 
the  instrument  and  by  electric  light  they  appear  as  pink  or  gelatinous 
masses  attached  to  the  wall  by  a  bright-red  cord.  This  cord  is  usually 
about  the  size  of  an  ordinary  shoestring,  but  it  may  be  much  larger. 
Grasped  between  the  fingers  they  usually  feel  soft  and  pliable,  but  occa- 
sionally firm  and  fibrous.  One  can  generally  feel  the  pulsation  of  the 
afferent  artery,  but  this  is  not  uniformly  the  case. 

Treatment. — The  treatment  of  these  growths  consists  in  snaring  them 
off  with  an  ordinary  rectal  snare  (Fig.  238),  or  if  they  can  be  grasped 
and  pulled  down,  a  ligature  may  be  applied  around  the  pedicle  and  the 
tumor  snipped  off  below  it.  If  the  patient  is  anaesthetized,  the  pedicle 
may  be  crushed  with  the  hsemorrhoidal  clamp,  the  tumor  cut  off,  and 
the  stump  cauterized.  In  children,  however,  anaesthesia  is  frequently 
unnecessary,  inasmuch  as  the  pedicles  are  devoid  of  nerve  fibers,  and 
one  may  drag  down 
the  tumor  and  apply 
a  ligature  or  crush 
the  pedicle  without 
any  pain.  Occasion- 
ally these  little  tu- 
mors are  attached 
by  a  broad  band  of 
mucous  membrane, 
which,  if  it  is  simply  cut  off,  will  leave  quite  an  ulcerative  space;  in 
such  cases  it  is  better  to  cut  the  tumor  off  and  suture  the  edges  of  the 
mucous  membrane  together  with  fine  catgut.  This  is  a  very  rare  con- 
dition in  single  or  mucous  polypi,  but  in  papillomata  and  adenomata 
with  broad  attachments,  the  precaution  is  very  important,  inasmuch 
as  it  is  the  only  method  by  which  the  entire  growth  can  be  removed, 
and  the  danger  of  recurrence  in  a  malignant  form  be  reduced  to  a 
minimum. 

Where  the  pedicle  is  very  slender  it  may  be  caught  and  twisted  with 
little  tension  until  it  is  loosened  from  its  attachment,  but  there  is  al- 
ways risk  of  tearing  the  mucous  membrane  of  the  gut  by  this  method, 
and  if  there  should  be  an  invagination  of  the  peritonaeum  into  the  pedi- 
cle this  might  be  opened. 

No  dressing  is  necessary  after  such  an  operation.  The  bowels 
should  be  encouraged  to  move  regularly,  and  the  rectum  should  be 
irrigated  with  antiseptic  solutions  daily  for  one  week,  after  which  time 
the  parts  will  probably  be  well. 

The  other  types  of  tumors  which  assume  the  polypoid  shape  will 
be  considered  under  their  proper  histological  classification.    The  pedun- 


FiG.  238. — Ladinski's  Rectal  Snare 


716 


THE  ANUS,   RECTUM,  AND   PELVIC   COLON 


Ciliated  form  is  only  a  morphological  characteristic  clue  to  the  elasticity 
and  mobility  of  the  tissues  in  which  they  develop,  and  to  the  peristaltic 
efforts  of  the  bowel  to  rid  itself  of  an  abnormal  object.  Thus  the  sig- 
nificance and  importance  of  a  tumor  of  the  rectum  depends  entirely  upon 

the  growth  at  the  end 
of  the  stem,  and  not  at 
all  upon  the  polypoid 
.<liape. 

Fibroma.  —  True 
fibromata  of  the  anus 
and  rectum  are  exceed- 
ingly rare.  They  have 
their  origin  in  the  con- 
nective tissue  of  the 
submucosa,  sometimes 
grow  to  considerable 
size  (Fig.  239),  and 
may  be  solid  or  cav- 
ernous. They  may  re- 
main in  the  rectal  wall 
or  they  may  assume 
the  form  of  polypi. 

Bowlby  (Transac- 
tions of  the  Patholog- 
ical Soc.  of  London, 
1882,  p.  107)  has  re- 
corded the  case  of  a 
woman  who,  while  at 
stool,  forced  out  from 
her  anus  a  tumor  of 
this  variety  as  large  as 
a  foetal  head.  It  was 
attached  by  a  pedicle 
to  the  anterior  wall  of 
the  gut  -i  inches  above  the  anus,  and  weighed  nearly  2  pounds.  On 
microscopic  examination  it  was  found  to  be  composed  almost  entirely 
of  pure  fibrous  tissue.  The  pedicle  was  simply  ligated  and  clamped  off 
below  the  ligature,  and  the  patient  made  an  excellent  recovery. 

Barnes  (Brit.  Med.  Jour.,  1879,  vol.  i,  p.  551)  described  a  tumor  of 
this  variety  as  large  as  an  orange,  which  he  removed  by  means  of  a 
galvanic  loop.  The  tumor  itself  was  composed  of  fibrous  tissue,  and 
was  cavernous  in  some  portions. 

Pathology. — A  pure  fibroma  consists  of  fibrous  tissue  arranged  in 


Fh..  239. — Fibroids  of  thi     \-     -    -.m)  Rkcttm. 

Drawn  t'roiri  photojrrapl]  taken  before  operation,  1894.     Nine 

distinct  tumors  were  removed. 


BENIGN  TUMORS  OF  THE  RECTUM  717 

wavy  bundles,  and  ordinarily  containing  very  few  blood-vessels,  but  in 
this  respect  there  is  considerable  variation.  Most  of  those  removed  are 
of  the  mixed  variety,  and  contain  more  or  less  muscular,  glandular,  and 
connective  tissues. 

Thus  what  is  ordinarily  known  as  a  fibrous  polypus  of  the  rectum 
is  not  in  reality  a  true  fibroid,  but  a  polypoid  tumor  in  which  the  fibrous 
tissue  in  varying  amount  is  mixed  with  glandular  and  other  elements. 
In  these  eases  the  fibrous  tissue  does  not  run  in  wavy  bundles,  but  ex- 
tends in  all  directions,  and  gives  to  the  tumor  its  density,  hardness,  and 
weight.  Owing  to  the  size  and  heaviness  of  such  growths,  the  pedicle  is 
much  dragged  upon,  and  consequently  becomes  very  weak  and  slender. 
It  may  be  ruptured,  and  the  tumor  brought  away  by  the  friction  of  the 
faecal  passages  or  by  the  peristaltic  action  of  the  intestines.  The  size 
of  the  tumors  varies  from  that  of  a  small  hazelnut  to  that  of  a  coconut; 
ordinarily  they  are  somewhat  elongated,  and  about  the  size  and  shape 
of  a  small  olive. 

Symptoms. — Fibrous  tumors  of  the  rectum  as  a  rule  do  not  occur  in 
children;  they  are  hard  and  sometimes  nodular;  the  mucous  membrane 
covering  them  is  somewhat  thickened,  and  occasionally  it  may  be  ulcer- 
ated, owing  to  the  pressure  of  the  faecal  mass  or  to  the  friction  produced 
by  the  tumor  moving  up  and  down  in  the  intestinal  canal.  Sometimes 
the  glandular  elements  in  these  tumors  contain  more  or  less  fluid  or 
jelly-like  mucus;  when  this  condition  exists,  the  tumor  is  termed  a 
colloid  polypus.  The  transformation  or  degeneration  of  these  tumors 
is  very  rare,  but  it  is  said  to  occur,  and  when  it  does,  a  sarcoma  is  the 
result. 

When  the  fibroma  remains  in  the  intestinal  wall  it  assumes  the  form 
of  a  spherical  or  ovoid  mass  closely  attached  to  the  muscular  coat,  and 
the  mucous  membrane  is  movable  over  it.  Its  seat  may  be  anywhere 
in  the  tract  from  the  margin  of  the  anus  to  the  stomach.  Fig.  239  is 
drawn  from  the  photograph  of  a  case  of  multiple  fibroids  of  the  anus 
occurring  in  the  writer's  practice. 

The  other  symptoms  are  similar  to  those  of  mucous  polypi.  Those 
in  the  wall  of  the  gut  give  rise  to  dull,  aching  pain,  tenesmus,  frequent 
defecation,  and  sometimes  ulceration  of  the  mucous  membrane.  The 
absence  of  haemorrhages  and  mucous  discharges  distinguishes  these 
growths  from  other  types  of  polypi. 

Enchondroma.- — One  of  the  rarest  tumors  of  the  connective-tissue 
variety  occurring  in  the  rectum  is  that  known  as  enchondroma.  Only 
two  instances  have  been  reported.  Van  Buren  (op.  cit.,  p.  268)  recorded 
a  case  of  this  type,  and  recently  Dolbeau  (Bull,  de  la  soc.  anat.,  t.  v, 
p.  6)  has  reported  a  case.  The  tumor  which  was  removed  from  the  rec- 
tum of  a  man  aged  twenty-seven  was  about  the  size  of  a  small  walnut. 


718  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

Histologically  it  was  composed  of  cartilaginous  and  fibrous  tissue.  In 
some  portions,  however,  it  appeared  to  be  of  an  adenomatous  nature, 
and  therefore  could  not  be  considered  a  pure  enchondroma. 

Lipoma. — Tumors  composed  of  adipose  tissue  are  found  in  the  rectal 
cavity,  and  also  higher  up  in  the  intestinal  canal;  when  they  occur 
in  the  rectum,  they  ordinarily  develop  from  the  submucous  layer  of  the 
intestinal  wall;  higher  up,  however,  they  sometimes  arise  from  the 
subperitoneal  fat. 

Ordinarily  these  tumors  are  closely  attached  to  the  rectal  wall,  but 
they  may  also  assume  a  polypoid  shape,  and  the  pedicle  may  attain  the 
length  of  5  or  6  centimeters  (2|  inches).  They  are  composed  of  moder- 
ately firm,  lobulated  masses,  consisting  of  fatty  cells  enclosed  in  a 
fibrous  stroma  varying  in  amount;  they  are  only  very  slightly  vascular, 
and  may  grow  to  a  size  which  may  obstruct  the  canal. 

Castellane  (Gazette  hebd.,  1870),  quoted  by  Molliere,  records  the 
case  of  a  man  aged  forty-three,  who  passed  from  his  rectum  an  ovoid 
tumor  12  centimeters  (4|  inches)  in  length  by  6  centimeters  (2f  inches) 
in  width,  of  a  firm  consistence,  pink  color,  and  lobulated.  The  tumor 
was  attached  by  a  pedicle  3  centimeters  (ly^^  inch)  in  length,  and  com- 
posed of  pure  lipomatous  tissue. 

Tedenat  (Montpelier  Med.  Jour.,  1885)  operated  upon  a  lipoma  of  the 
rectum  13  centimeters  (5^  inches)  in  length  and  6  in  depth,  which  was 
attached  by  a  pedicle  the  size  of  the  index  finger  inserted  12  centi- 
meters (4f  inches)  above  the  anus.  This  tumor,  which  entirely  oc- 
cluded the  rectum,  was  removed  by  an  ecraseur.  The  mucous  membrane 
covering  the  growth  was  thickened,  oedematous,  and  ulcerated.  Bernard 
(Molliere,  op.  cit.,  p.  525)  has  recorded  a  similar  case. 

Yirchow  (Path,  de  tumeurs,  vol.  i,  p.  379)  has  recorded  a  case  in 
which  there  was  an  invagination  of  the  colon  into  the  rectum  due  to 
two  submucous,  pedunculated  lipomata.  Each  of  these  tumors  was 
about  the  size  of  an  egg.  Esmarch,  Bose,  Broca  (Archiv  f.  klin.  Chirur., 
1876),  Afezon  (Bull,  de  soc.  d'anat.,  Paris,  1875),  have  all  recorded 
similar  cases.  Voss  has  reported  a  case  in  which  the  tumor,  situated  in 
the  rectal  wall,  caused  a  prolapse  of  this  organ,  and  was  thus  protruded 
through  the  anus  when  the  bowel  moved.  He  split  the  mucous  mem- 
brane and  enucleated  the  tumor,  after  which  the  prolapse  disappeared. 

Spencer  Wells  (Transactions  of  the  Path.  Soc.  of  London,  vol.  xvi, 
p.  277)  speaks  of  the  occurrence  of  lipomata  in  the  recto-vaginal  sreptum. 
Molk  (Thesis,  Strasburg,  1868)  described  a  number  of  perineal  lipo- 
mata, some  of  which  were  pedunculated  and  others  not.  Roberts  (An- 
nales  de  therap.,  1844)  gives  the  history  of  a  man  upon  whom  he  oper- 
ated for  what  he  considered  a  perineal  hernia,  but  which  he  found  to 
be  a  lipoma  originating  in  the  ischio-rectal  fossa. 


BENIGN  TUMORS  OP   THE   RECTUM  Yl9 

The  author  has  seen  two  cases  of  lipoma  of  the  rectum  and  one  of 
the  anus.  One  of  those  in  the  rectum  assumed  the  polypoid  form,  and 
was  attached  to  the  anterior  wall  ahout  4  inches  above  the  anus.  The 
other  tumor  was  located  in  the  rectal  wall  just  in  front  of  the  sacrum. 
This  tumor  was  lobulated^  about  the  size  of  a  small  hen's  egg,  and  was 
supposed  to  be  a  dermoid  cyst.  An  incision  was  made  in  the  mucous 
membrane,  and  the  tumor  enucleated;  it  proved  to  be  a  pure  lipoma,  and, 
so  far  as  could  be  judged,  was  confined  between  the  muscular  and 
mucous  layers  of  the  gut. 

Tumors  of  this  class  occasionally  occur  outside  of  the  rectum,  and 
yet  attached  to  its  walls,  occasioning  by  their  pressure  tenesmus  and 
obstruction  of  the  canal. 

Vorchung  (Transactions  of  the  Path.  Soc.  of  London,  vol.  xv,  p.  100) 
has  reported  a  case  of  this  kind  seen  in  a  woman  who  had  suffered  during 
life  from  retention  of  f^ces  and  difficulty  in  urination.  She  died  from 
mechanical  obstruction  to  the  passage  of  urine.  Upon  post-mortem 
there  was  found  a  lipoma  in  the  pelvis  completely  surrounding  the 
rectum,  and  firmly  attached  to  its  outer  walls.  The  growth  en- 
tirely obstructed  the  two  ureters,  and  almost  completely  occluded  the 
rectum. 

When  such  tumors  are  attached  by  pedicles  inside  of  the  rectum, 
they  are  very  likely  to  be  torn  off  as  other  polypi  are;  the  pedicle  may 
be  twisted,  and  on  account  of  the  circulation  being  impaired  becomes 
friable  and  easily  ruptured. 

Where  the  tumors  are  large  and  the  pedicles  extensive,  there  may 
be  funnel-shaped  invaginations  of  the  peritonseum  into  them.  This,  of 
course,  occurs  when  the  pedicle  is  attached  to  the  anterior  or  lateral 
portions  of  the  rectum  or  sigmoid.  Ball  (op.  cit.,  p.  298)  states  that  this 
fact,  together  with  the  history  of  most  of  these  tumors  having  descended 
from  the  sigmoid  flexure,  tends  to  show  that  they  originate  in  the  appen- 
dices epiploicse,  which  have  become  inverted,  and  are  thus  carried  down- 
ward into  the  rectimi  in  the  shape  of  polypi.  There  is  little  ground  for 
this  theory,  as  the  tumors  have  never  been  shown  to  be  surrounded  by 
the  remains  of  a  peritoneal  membrane,  which  would  necessarily  be  the 
case  were  their  origin  such  as  Ball  suggests. 

Treatment. — The  removal  of  these  tumors  when  pedunculated  should 
always  be  carried  out  by  the  use  of  the  ligature,  owing  to  the  possibility 
of  peritoneal  invagination  into  the  pedicle.  If  they  are  cut  oif  with 
scissors  or  torn  loose  recklessly,  these  little  infundibular  invaginations 
may  be  opened,  and  thus  connect  the  peritoneal  cavity  with  that  of  the 
rectum,  which  must  inevitably  result  in  septic  peritonitis. 

The  snare  and  wire  ecraseur  and  the  clamp  are  none  of  them  suitable 
in  such  cases.     Where  the  tumor  is  situated  in  the  rectal  wall  and  is 


720  THE   ANUS,   RECTU-M.   AND   J'ELVir   COL(»N 

not  pcdunculati'd.  it  should  l)o  removed  by  incision  of  the  mucous  mem- 
brano,  enucleation,  and.  if  possible,  suturing  of  the  wound. 

Myoma. — Tumors  composed  of  muscular  or  combined  muscular  and 
fibrous  tissue  occasionally  occur  in  the  rectum.  They  arise  from  the 
muscular  coat — generally  the  longitudinal  layer — and  assume  a  nodular 
form  supplied  with  a  pedicle,  or  sometimes  they  exist  as  broad  tumors 
lying  in  the  muscular  wall  of  the  intestine  and  covered  by  the  submucous 
and  mucous  coats.  They  are  ordinarily  chissed  among  the  leiom3'omas 
and  are  composed  of  unstriped  muscular  fibers.  Microscopically  they 
consist  of  great  numbers  of  muscular  fibers  separated  by  a  connective- 
tissue  network.  Where  the  fibrous  tissue  exists  in  any  considerable 
quantities,  the  tumor  may  be  called  a  fibromyoma.  They  are  not  mark- 
edly vascular,  the  capillaries  ordinarily  running  in  the  fibrous  stroma 
of  the  growth. 

Tedenat  (op.  cit.)  has  described  myomata  which  he  removed  from 
the  rectum  of  a  man  in  whom  they  caused  ha?morrhages  and  mucous 
discharges.  De  Carlier  (Jour,  de  med.  chirur.  and  pharm.  des  Bruxelles, 
1881,  p.  140)  successfully  removed  a  tumor  from  the  rectum  which  was 
found  to  be  a  pure  myoma.  Heurtaux  (Archives  provincials  de  chirur., 
1896,  p.  189)  has  recorded  similar  cases. 

Berg  and  Senn,  cited  by  "Westermark  (Centralblatt  f.  Gyniik.,  1896), 
have  reported  cases  in  which  they  have  removed  fibromyomata  from  out- 
side of  the  rectum,  but  closely  attached  to  this  organ.  In  Berg's  case 
the  tumor  filled  the  hollow  of  the  sacrum,  and  was  closely  attached  to 
the  rectal  wall,  the  mucous  membrane  of  the  gut  being  inflamed,  thick- 
ened, and  ulcerated.  The  growth  was  removed  by  the  Kraske  operation. 
In  Senn's  case  the  tumor  partially  filled  the  pelvis  and  was  closely  at- 
tached to  the  anterior  wall  of  the  rectum.  "Westermark  himself  reports 
a  similar  case  in  which  the  anterior  wall  of  the  rectum  was  ruptured 
during  the  operation,  and  death  followed  on  the  fourth  day  from  peri- 
tonitis. In  his  case,  however,  microscopic  examination  showed  the 
tumor  to  be  a  pure  fibromyomata,  originating  in  the  longitudinal, 
muscular  fibers  of  the  gut.  McCosh  (Annals  of  Surgery,  1893,  p.  41) 
operated  upon  a  tumor  of  this  kind  which  was  situated  outside  of  the 
gut  and  attached  to  its  posterior  wall.  He  found  it  necessary  to  per- 
form a  preliminary  colotomy,  after  which  he  removed  the  growth  by  a 
shallow  incision,  at  the  same  time  excising  the  coccyx  and  removing  a 
part  of  the  wall  of  the  gut  to  which  the  tumor  was  attached.  His  patient 
made  a  good  recovery. 

These  tumors,  however,  are  quite  rare,  and  it  is  impossible  to  deter- 
mine their  nature  without  a  thorough  microscopic  examination.  If  they 
are  small  and  confined  to  the  rectal  wall,  the  hard,  nodular  surface  may 
frequently  lead  one  to  the  diagnosis  of  scirrhous  cancer. 


BENIGN  TUMORS  OF  THE  RECTUM  721 

Treatment. — The  only  thing  to  be  done  with  such  growths  is  to  re- 
move them.  If  feasible,  this  should  be  done  from  the  outside  of  the 
rectum.  When  the  mucous  membrane  is  freely  movable  over  the  tumor 
and  the  latter  is  not  more  than  4  inches  above  the  anus,  this  can  gener- 
ally be  accom^Dlished.  After  it  is  done,  the  muscular  wall  of  the  gut  from 
which  the  tumor  is  excised  should  be  sutured  as  accurately  together  as 
joossible.  If  done  within  the  rectum,  great  care  should  be  exercised  to 
furnish  free  drainage  to  the  parts  even  if  complete  posterior  proctotomy 
has  to  be  performed  to  accomiDlish  this. 

Lymphadenoma. — This  type  of  growth  is  occasionally  found  in  the 
rectum.  It  develops  from  the  lymphoid  tissues  or  solitary  nodes  which 
exist  throughout  the  large  intestine.  It  is  soft  to  the  touch,  and  may 
attain  a  considerable  size.  It  consists  of  a  reticulum  formed  by  branch- 
ing cells  united  by  their  prolonged  extremities.  Within  the  meshes  thus 
formed  there  lie  round  cells  with  circular  nuclei.  Stengel  states  that 
the  cells  are  less  uniform  in  size  than  those  of  the  normal  lymphatic 
glands,  and  large  cells  are  in  abundance. 

Felizet  and  Brancha  (Traite  des  malad.  de  I'enfance,  1897,  t.  ii,  p. 
747)  state  that  in  these  tumors  there  are  two  zones,  the  peripheral,  com- 
posed of  mucous  membrane  from  which  the  glandular  culs-de-sac  have 
disappeared,  and  the  central,  composed  of  irregular  lobules  separated  by 
connective-tissue  bands.  In  the  delicate  reticulum  are  found  various- 
sha^Jed  leucocytes  and  capillaries,  the  lumen  of  which  is  separated  from 
the  adenoid  tissue  by  a  thin  ring  of  connective  tissue. 

Quenu  and  Hartmann  state  {op.  cit.,  vol.  ii,  p.  361)  that  these  growths 
are  usually  pedunculated,  and  cite  cases  from  Schwab  (Beitr.  z.  klin. 
Chir.,  Bd.  xviii,  S.  2),  M.  Broca,  Shattock  (Trans.  Path.  Soc,  London, 
1890,  p.  137),  and  Branca  (Bull,  de  la  soc.  anat.,  Paris,  1897,  p.  158) 
to  corroborate  this  view.  In  the  author's  case  there  was  no  peduncula- 
tion  whatever.  Ball  (op.  cit.,  p.  321)  describes  a  tumor  of  this  kind,  but 
states  that  upon  minute  examination  it  proved  to  be  a  lympho-sarcoma. 
He  states  that  a  number  of  such  growths  have  been  recorded  in  connec- 
tion with  Hodgkin's  disease.  It  is  important,  therefore,  to  know  that 
we  are  not  dealing  with  sarcoma  before  giving  a  prognosis  in  such  cases. 

Symptoms. — L^miphadenoma  present  no  other  symj^toms  than  those 
of  a  single  pol}'p.  They  may  prolapse  and  produce  mechanical  irritation 
of  the  rectum,  but  they  do  not  bleed  freely,  and  discharge  no  mucus  or 
pus.  A  glairy  mucous  discharge  may  be  associated  with  them,  but  this 
is  due  to  a  catarrhal  proctitis  excited  by  the  pressure  of  the  neoplasm. 
The  tumors  are  slightly  lobulated,  always  single,  of  a  bright-red  color 
and  soft  consistence. 

Treatment. — The  treatment  consists  in  their  radical  removal  by  sur- 
gical measures.  The  cases  recorded  are  too  few  from  which  to  draw 
46 


722  THE  AXUS,  RECTUM,  AND   PELVIC  COLON 

auy  general  conelusioiis,  but  so  far  those  not  exhibiting  sarcomatous 
changes  have  shown  no  tendency  to  recur,  and  the  parts  have  healed 
promptly  after  operation. 

These  tumors  liave  been  put  down  by  authors  generally  as  of  a  benign 
nature,  but  both  Stengel  and  Ziegler  consider  them  as  frequently  malig- 
nant.    Complete  and  wide  removal  should  therefore  be  made. 

Myxoma. — This  type  of  tumor  consists  of  a  soft  and  more  or  less 
flabby  growth  enclosed  by  a  thin  capsule,  and  has  a  spherical  outline. 

It  may  assume  the  polypoid  shape,  or  occur  as  a  semispherical  pro- 
tuberance in  the  rectum.    It  is  composed  of  stellate,  irregular  cells  and 

a  gelatinous  intercellular  substance. 
Occasionally  it  is  lobulated,  but  or- 
dinarily its  surface  is  quite  smooth. 
It  is  rare  that  a  pure  myxoma 
is  ever  found,  the  myxomatous  be- 
ing usually  mixed  with  tibrous,  fat- 
ty, cartilaginous,  or  sarcomatous 
tissue.  Microscopically  these  tu- 
mors consist  in  a  homogeneous, 
somewhat  glandular  tissue,  with 
surfaces  due  to  the  refraction  of 
the  light.  An  excess  of  the  round, 
granular  cells  sometimes  gives  the 
appearance  of  a  myxo-sarcoma. 
"Within  this  mass  of  myxomatous  tissue  there  lie  stellate,  spindle-shaped, 
connective-tissue  cells  (Fig.  240).  According  to  Stengel,  the  vascular 
supply  is  poor,  and  the  blood-vessels  are  only  partially  developed.  Zieg- 
ler, however,  states  that  the  tissue  is  translucent,  and  the  blood-vessels 
are  plainly  visible  when  they  are  filled  with  blood. 

The  soft  rectal  polypi  of  children  are  practically  myxomata.  Hulke 
(Med.  Times  and  Gaz.,  vol.  ii,  p.  1066)  has  recorded  a  case  of  myxoma  in 
which  the  tumor  surrounded  the  rectum  and  anus,  almost  occluding 
the  canal.  It  was*  entirely  outside  of  the  gut,  however,  and  occupied 
the  perina'iim  and  ischio-rectal  fosss. 

Adenoma. — The  term  adenoma  as  applied  to  the  rectum  is  ordinarily 
considered  S}Tionynious  with  polypus.  The  fact  that  a  large  number  of 
rectal  polypi  are  of  the  adenomatous  variety,  and  that  even  multiple 
adenomas  assume  the  polypoid  shape,  has  led  many  to  consider  these 
two  conditions  identical,  but  this  is  not  the  fact.  Almost  every  tumor 
of  the  rectum  may  become  pohqooid,  but  this  has  nothing  to  do  with  its 
pathological  nature.  It  is  only  one  variety  of  polymorphism  to  which 
neoplasms  are  subject  in  a  movable  and  loose  tissue.  All  polypi  are 
not  adenomas,  neither  are  all  adenomas  polypi. 


-MvxoMA  I  Stengel  I 


BENIGN  TUMORS  OF   THE  RECTUM  T23 

The  earliest  descriptions  of  adenomas  of  the  rectum  date  back  to 
the  sixteenth  century.  Leautaud,  Lange,  Schmucker^  Felizet,  and  Bran- 
ca described  them  in  1760;  the  first  accurate  description  was  given  by 
Stoltz  in  1841,  who  afterward  published  a  most  interesting  article  on 
the  rectal  polypi  of  children  (Gaz.  med.  de  Strasburg,  1859,  p.  157,  and 
1860,  p.  7). 

In  recent  years  Ball,  Bardenheuer,  Cripps,  Kelsey,  Luschka,  Tan- 
chard,  Weichselbaum,  Dalton,  and  others  have  made  careful  pathological 
examinations  and  studies  of  these  conditions.  Quenu  and  Hartmann 
have  gone  very  carefully  into  the  subject,  and  to  those  interested  in 
the  minute  pathology  their  work  will  be  of  exceeding  interest.  It  is  too 
detailed  and  technical,  however,  for  the  general  practitioner,  who  must 
depend  finally  upon  the  pathologist  to  decide  upon  the  histological  na- 
ture of  neoplasms. 

Adenomas  develop  from  the  mucous  and  submucous  coat  of  the  rec- 
tum. Quenu  and  Hartmann  state  that  they  do  not  extend  below  the 
muscularis  mucosa;  Cripps,  on  the  contrary,  holds  that  they  involve  the 
entire  thickness  of  the  mucous  membrane  and  submucosa.  At  any  rate 
all  the  elements  composing  these  layers,  the  epithelial,  the  tubular,  the 
fibrous,  and  the  glandular  constituents,  are  found  in  them. 

The  tumors  may  occur  singly  or  multiple.  In  children  there  are 
ordinarily  only  one  or  two,  and  these  are  of  a  distinctly  polypoid  form 
with  pedicles  of  considerable  length.  In  adults,  however,  they  are  gener- 
ally multiple,  and  the  pedicles  are  not  so  marked. 

Histologically,  the  single  tumors  found  in  children  consist  of  a 
greater  amount  of  connective  or  fibrous  tissue  in  proportion  to  the 
glandular  and  epithelial  structures.  In  the  multiple  tumors,  found 
chiefly  in  adults,  the  proportion  is  reversed,  and  there  is  an  excess  of 
the  epithelial  and  glandular  elements  in  proportion  to  the  connective- 
tissue  stroma.  On  this  account  adenomas  of  the  multiple  variety  ap- 
proach more  closely  the  epitheliomatous  or  cylindrical  carcinomatous 
type  than  do  the  single  adenomas  of  childhood. 

Simple  Adenomas. — They  occur  most  frequently  in  children  from 
one  to  twelve  years  of  age,  although  they  are  occasionally  seen  in  adults. 
The  tumors  vary  in  size  from  a  small  cherry  to  that  of  a  hen's  egg, 
or  even  larger;  there  may  be  only  one  or  there  may  be  three  or  four. 
Between  this  number  and  multiple  adenoma  there  is  no  middle  ground. 

Cases  have  been  reported  by  Kaemm,  Ball,  and  others  in  which  a 
single  adenoma  reached  enormous  size  and  weighed  as  much  as  4 
pounds.  Quenu  and  Hartmann,  in  an  examination  of  15  cases,  observed 
none  of  them  larger  than  an  ordinary  nut.  In  the  author's  experience 
one  single  adenoma  as  large  as  a  hen's  egg  has  been  seen;  the  rest  of 
them  varied  in  size  from  a  small  pea  to  that  of  an  English  walnut. 


724:  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

In  a  case  of  multiple  adenoma,  however,  one  of  the  growths  absolutely 
filled  up  the  caliber  of  the  gut.  In  the  single  variety,  in  which  the  poly- 
poid form  is  marked,  the  pedicles  may  measure  from  1  to  4  or  5  inches 
in  length;  in  1  case,  after  ligating  it  3  inches  above  the  anus,  the  pedicle 
could  be  felt  dangling  down  in  the  rectum  from  above.  Although  no 
accurate  measurement  was  made,  it  w^as  apparently  5  or  6  inches  long. 
The  size  of  the  pedicle  varies  with  the  age  and  size  of  the  tumor. 
Where  the  latter  has  existed  for  a  long  time,  and  has  been  gradually 
dragged  upon  and  stretched,  the  pedicle  becomes  much  attenuated.  Or- 
dinarily it  may  be  said  to  be  about  the  size  of  a  round  shoestring,  or  in 
proportion  to  the  tumor,  about  ^  of  its  diameter.  The  tumors  appear 
to  the  naked  eye  as  spherical  knobs  upon  the  end  of  the  stems.  They 
are  oval  in  form,  bright  red,  and  resemble  very  much  a  large  red  rasp- 
berry. The  mucous  membrane  covering  the  stem  or  pedicle  is  normal 
with  the  exception  that  the  tubules  are  decreased  and  the  epithelium 
is  somewhat  atrophied.  Within  the  pedicle  the  fibrous  core  or  center 
passes  in  longitudinal  layers  through  its  tissues  until  it  reaches  the 
tumor,  at  which  point  these  fibers  branch  out,  forming  a  sort  of  arbo- 
rescent growth.  These  branches  form  the  center  or  base  of  the  lobes 
composing  the  tumor.  According  to  the  observations  of  Quenu  and 
Hartmann,  this  fibrous  stalk  and  branches  appear  to  grow  from  the 
septa  between  the  Lieberkiihn  follicles,  and  not  to  proceed  from  the 
submucosa.  From  the  fact  that  we  very  rarely  find  muscular  fibers 
in  the  stalks^  it  would  seem  that  these  observations  are  correct,  bvit 
Cripps  does  not  accept  them.  He  believes  that  they  grow  from  the 
submucosa.  The  blood-vessels  proceed  directly  from  the  submucosa, 
and  can  be  traced  downward  into  this  tissue.  From  each  of  the  fibrous 
stalks  which  branch  off  to  form  the  lobules,  fine  branches  pass  outward, 
forming  a  sort  of  reticulum  upon  which  the  ojiitlielial  cells  that  prac- 
tically compose  the  tumor  rest. 

The  epithelium  covering  these  stalks  is  always  of  the  columnar 
variety,  and  composed  of  goblet  and  cylindrical  cells,  thcTiuclei  of  which 
are  ordinarily  near  the  base.  The  epithelium  is  arranged  in  a  single 
layer  more  or  less  closely  packed  together,  and,  according  to  Cripps 
(op.  cit.,  p.  288),  is  always  continuous  with  the  epithelium  covering 
the  stalk,  and  through  this  with  that  lining  the  intestinal  canal.  The 
firmness  and  vascularity  of  the  tumor  will  depend  upon  the  amount 
of  fibrous  tissue  in  the  stalk  and  the  length  of  its  ramifications.  Wliere 
the  fibrous  tissue  is  small  and  the  ramifications  very  long,  the  tumor 
will  be  soft,  vascular,  and  bleed  very  easily. 

Alterations  in  the  volume,  diameter,  and  shape  of  the  tubules  occur 
owing  to  inflammatory  processes  and  pressure.  Those  nearest  normal 
will  be  found  at  the  pedicle,  and  gradually  increasing  alterations  will 


BENIGN  TUMORS  OF   THE   RECTUM  725 

be  more  and  more  marked  as  one  proceeds  toward  the  peripher}-  of 
the  tumor.  A'ariations  in  form  and  height,  the  predominance  of  mncip- 
arotis  cells  and  degeneration  of  the  protoplasm  and  nuclei,  characterize 
the  changes  in  the  epithelium  of  these  growths.  In  some  cases  the 
outlines  of  the  cells  are  not  at  all  visible,  they  are  simply  recognized 
by  numerous  nuclei  surrounded  by  an  indistinct  protoplasm  (Quenu 
and  Hartmann,  yoI.  ii,  p.  34). 

The  surface  epithelium  is  frequently  absent,  owing  to  the  friction 
of  the  fgecal  masses  and  the  rubbing  up  and  down  of  the  tumor  against 
the  rectal  wall.  In  the  depressions  and  near  the  attachment  of  the 
pedicle,  the  normal  epithelium  of  the  rectum  is  ordinarily  found.  The 
connective  tissue  of  the  t,umor  itself  presents  a  fibrillary  appearance 
composed  of  young  cells,  and  resembling  very  much  the  chorion  of  the 
mucous  membrane.  It  varies  greatly  in  quantity.  In  some  it  is  very 
marked  and  gives  the  tumor  a  firm,  hard  feeling;  in  others  the  glandular 
acini  and  tubules  are  relatively  large,  and  give  it  a  soft,  cystic  ap- 
pearance. 

These  tumors  may  undergo  secondary  degenerative  changes,  such  as 
hyaline,  myxomatous,  or  cystic  degeneration,  under  Avhich  circumstances 
they  would  be  called  cylindroma,  adeno-myxoma,  and  cystadenoma. 

While  adenomas  are  ordinarily  considered  benign  growths,  they  are 
said  in  some  cases,  even  in  their  pure  form,  to  give  rise  to  metastasis. 
They  have  no  effect  upon  the  general  health  in  themselves,  although 
this  may  be  influenced  through  their  local  irritation  and  interference 
with  the  normal  functions,  or  through  ulceration  and  haemorrhage. 

Symptoms. — Simple  adenomas  nearly  always  assume  a  polypoid 
form,  and  the  symptoms  are  identical  with  those  of  other  polypi,  except 
that  they  bleed  more  easily.  The  important  points  are,  that  in  adults 
where  one  is  found  many  others  are  likely  to  exist,  and  after  removal 
they  are  likely  to  recur. 

Treatment. — The  treatment  of  this  type  of  tumor  is  very  simple. 
They  may  be  twisted,  tied,  crushed,  or  snared  off.  It  is  not  necessary 
that  the  pedicle  should  be  caught  close  to  the  wall  of  the  gut.  Any 
remaining  stump  will  atrophy  and  disappear  if  all  the  adenoid  tissue 
is  removed.  If  the  growth  is  sessile  or  attached  by  a  broad  pedicle, 
it  should  be  removed  by  wide  incision  through  the  mucous  membrane 
down  to  the  muscular  wall,  and  the  edges  of  the  wound  should  be 
sutured  together  by  catgut. 

The  possibility  of  invagination  of  the  peritoneum  into  the  pedicle 
should  always  be  remembered,  and  on  this  account,  if  the  tumor  is  high 
enough  for  this  to  occur,  it  should  be  tied  off  with  a  strong  silk  ligature. 

Multiple  Adenomata. — In  adults,  and  occasionally  in  children,  the 
rectum,  sigmoid,  and  the  entire  colon  may  be  the  seat  of  multij^le  ade- 


726  THE  ANUS,   RECTUM,   AND  PELVIC  COLON 

nomata.  The  symptoms,  course,  and  pathology  of  this  condition  differ 
in  many  respects  from  those  of  simple  adenomata,  and  justify  a  distinct 
consideration.  Virchow  (Die  krankhaften  Gcschvviilste,  1863,  Bd.  i,  S. 
243-244)  has  described  it  under  two  titles:  "Polypi  of  the  large  intes- 
tine "  and  "  polypoid  colitis."  In  these  papers  he  does  not  seem  to 
have  recognized  the  rectum  as  a  seat  of  the  disease.  Cripps  speaks  of 
it  as  disseminated  polypi  of  the  rectum,  but  does  not  connect  it  with 
the  sigmoid  or  colon. 

There  have  been  very  numerous  reports  of  cases  of  this  type,  espe- 
cially during  the  last  few  years  (Whitehead,  Cripps,  Gerster,  Kelsey, 
Ball,  White,  etc.).  We  are  indebted  to  Quenu  and  Landel  (Revue  de 
chirurgie,  1899,  torn,  xix,  pp.  465-494)  for  the  most  exhaustive  review 
of  the  subject,  and  an  excellent  pathological  report  of  2  cases  occurring 
in  their  own  practice.  In  their  paper  42  cases  are  collected,  most  of 
which  have  been  observed  since  1884;  previous  to  their  studies,  surgeons 
generally  considered  these  tumors  as  identical  with  simple  adenoma  or 
polypus  of  the  rectum.  They  have  pointed  out,  however,  not  only  a 
difference  in  the  ages  at  which  the  two  conditions  occur,  but  also  cer- 
tain histological  and  pathological  variations  between  the  simple  and 
multiple  growths  that  render  this  view  of  identity  untenable. 

Etiology. — A  certain  number  of  surgeons  and  pathologists  seem  to 
believe  that  multiple  adenomata  originate  in  the  simple  type;  there  is 
no  case  reported,  however,  in  which  a  single  or  simple  adenoma,  recog- 
nized during  childhood,  has  ever  developed  into  the  multiple  variety  in 
after  years.  In  all  the  cases  observed  so  far,  not  one  has  been  reported 
in  which  a  single  isolated  tumor  was  found  in  the  beginning  and  fol- 
lowed by  the  development  of  numerous  others  afterward.  Wherever  a 
clear  and  distinct  history  is  furnished,  there  has  been  observed  in  the 
beginning  numerous  neoplasms  similar  in  size  and  stage  of  development. 
There  is  therefore  no  ground  to  believe  that  the  single  or  simple 
adenomata  of  children  are  predisposing  causes  of  multiple  adenomata 
in  adult  life. 

Age. — While  there  are  a  few  cases  of  the  multiple  type  reported  in 
children,  it  is  especially  a  disease  of  adult  life.  Of  the  42  cases  col- 
lected by  the  authors  mentioned,  over  50  per  cent  of  them  were  between 
twenty  and  thirty-five  years  of  age;  4  cases  occurred  below  sixteen,  and 
8  above  forty-five  years  of  age.  The  author  has  observed  6  cases,  3  in 
his  own  and  3  in  the  practice  of  colleagues,  all  of  which  were  between 
twenty  and  forty  years  of  age;  it  seems,  therefore,  to  be  a  disease  of 
middle  life. 

Sex. — There  appears  to  be  a  slight  preponderance  in  favor  of  the 
female  sex.  In  the  author's  cases,  2  were  in  women  and  1  in  a  man;  in 
those  seen  through  the  courtesy  of  Drs.  Gerster,  Ladinski,  and  Thomp- 


BENIGN  TUMORS  OF  THE  RECTUM  727 

son,  all  were  in  women.  There  is  no  reason,  however,  to  believe  that 
sex  exercises  any  etiological  influence. 

The  exact  cause  of  adenoma  is  not  well  known.  They  consist  in  an 
inflamed  hyperplasia  of  the  normal  glands  of  the  rectum.  Whether  this 
inflammation  may  occur  in  utero  has  not  yet  been  determined;  but  in 
view  of  the  fact  that  they  are  sometimes  observed  very  early  in  life,  it 
would  seem  that  such  was  possible. 

Heredity  has  some  influence,  as  was  pointed  out  by  Esmarch,  but 
inflammation  or  irritation  is  generally  accepted  as  the  chief  cause.  The 
action  of  certain  parasites,  such  as  distoma  ha?matobium,  and  microbic 
infection  of  the  glandular  tissues,  have  also  been  accused  of  having  an 
etiological  influence.  Francis  Huber,  of  New  York,  has  recently  made 
an  elaborate  study  of  this  subject,  and  shows  that  a  large  number  of 
children  suffering  from  postnasal  adenoids  also  suffer  from  rectal 
polypi.  He  argues  that  they  all  belong  to  that  class  of  cases  in  which 
there  are  lymphoid  hypertrophies  and  "  other  manifestations  of  the 
constitutio  lymphaticus,  status  lymphaticus." 

In  children  there  is  no  doubt  that  there  is  some  ground  for  such 
belief,  but,  so  far  as  adults  are  concerned,  there  is  no  proof  that  adenoids 
of  the  intestinal  canal  are  in  any  way  related  to  those  of  the  respiratory 
apparatus.  While  the  growths  in  the  rectum  and  in  the  nares  resemble 
each  other  somewhat,  this  resemblance  does  not  amount  to  an  identity 
by  any  means.  The  fact  that  rectal  adenoids  are  so  frequently  trans- 
formed into  carcinoma,  and  this  transformation  is  rarely  if  ever  seen 
in  the  postnasal  growths,  would  lead  one  to  conclude  that  there  was 
a  very  distinct  difference  between  them. 

Huber's  argument  is  interesting,  but  it  will  require  a  very  much 
larger  series  of  cases  to  prove  that  all  adenoids  of  the  rectum  are  the 
result  of  general  lymphatic  hypertrophy. 

Distribution  of  the  GrowtJis. — The  condition  is  said  by  some  to  be  an 
affection  of  the  colon  and  not  of  the  rectum;  yet,  as  a  matter  of  fact,  they 
are  rare  in  the  intestinal  canal  unless  the  rectum,  and  pelvic  colon  are 
also  involved.  In  the  majority  of  cases  they  are  as  numerous  and  large 
in  these  portions  of  the  tract  as  elsewhere.  In  50  cases,  adenomata 
existed  in  the  rectum  in  at  least  48;  they  were  confined  to  this  portion 
in  15;  in  11  they  were  only  in  the  rectum  and  sigmoid;  in  13  (Quenu  and 
Landel)  they  occupied  all  of  the  colon;  in  3  the  entire  intestine  and 
stomach,  and  in  2  the  colon  only.  From  these  figures  it  would  seem 
that  the  rectum  is  the  portion  of  the  intestinal  canal  most  frequently 
affected. 

Fink  states  that  they  begin  in  the  rectum  and  gradually  multiply 
upward;  they  are  sometimes  grouped  in  certain  regions,  and  seem  to 
be  restricted  to  these;  in  some  cases  aggregations  exist  in  the  rectum  or 


728 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


in  the  sigmoid  and  in  tlie  transverse  colon,  with  three  lengths  of  per- 
fectly healthy  mucous  membrane  between  them. 

The  sites  at  which  they  most  frequently  occur  in  great  abundance 
arc  those  at  which  the  fa-cal  mass  is  accustomed  to  be  arrested.  This  fact 
gives  color  to  the  theory  that  they  are  due  to  irritation  or  infection  of 

the  glands  by  the  facal 
material. 

Conformation. — The 
tumors  vary  exceeding- 
ly in  size,  form,  and 
appearance.  They  may 
be  smooth,  round,  and 
shiny,  or  rough  and 
wart-like,  resembling  a 
raspberry  (Fig.  241); 
they  may  be  spherical, 
elongated,  or  even  cy- 
lindrical in  their  shape, 
sometimes  resembling 
the  tail  of  a  large 
lumbricoid  worm  (Fig. 
242),  and  their  size 
varies  from  that  of  a 
hempseed  to  a  good- 
sized  egg.  In  some 
cases  the  pedicles  of 
the  different  tumors 
may  be  confluent, 
forming  one  general 
stem  from  which  sev- 
eral tumors  shoot  out 
like  grapes  in  a  bunch. 
The  author  saw  a 
case  of  this  kind  some 
years  ago,  in  which  the 
mass  of  adenoids  was 
as  large  as  one's  fist,  and  the  pedicle  as  large  around  as  the  wrist, 
though  soft  and  without  induration.  It  was  attached  about  2^  inches 
above  the  anal  margin,  and  the  mass  was  so  large  that  he  was  unable 
to  introduce  his  finger  far  enough  to  determine  whether  there  were 
any  other  adenomas  above  it  or  not.  The  patient  was  a  timid  soul, 
and,  refusing  an  operation,  disappeared  from  the  clinic. 

The  tumors  may  also  occur  in  the  papillary  form  in  which  the  villi 


Fio.  241. — Multiple  Adenomata  of  the  Rectum. 


BENIGN  TUMORS  OF   THE  RECTUM 


729 


are  very  nuicli  exaggerated^,  bulb-shaped,  and  resemble  the  so-called 
villous  tumor. 

Color. — The  color  of  the  growths  depends  very  largely  upon  the 
stage  and  the  part  of  the  intestine  in  which  they  are  seen.  If  they  are 
loose  in  the  rectum  and  of  comparatively  young  growth,  they  appear 
bright-red,  yellowish,  or  sometimes,  owing  to  their  being  coated  with 
mucus,  a  sort  of  reddish  gray.  If  they  are  old  and  inflamed  they  as- 
sume a  dark,  purplish-red  color,  and  one  frequently  sees  points  of  abra- 
sion or  ulceration  upon  their  surfaces. 

When  they  are  protruded  from  the  anus,  owing  to  the  torsion  or 
strangulation  of  their  blood-vessels  by  the  sphincters,  they  appear  dark, 
purplish-red,  or  even  black,  approaching  the  stage  of  gangrene. 

Consistence. — The  tumors  themselves  may  be  soft  or  hard,  according 
to  the  amount  of  connective-tissue  stroma  and  the  extent  to  which  car- 


FiG.  242. — Hypertrophic  Folliculitis  of  Eectum  and  Colon  (Lilienthal's  case). 

cinomatous  transformation  has  taken  place.  The  harder  the  tumor,  as 
a  rule,  the  more  likely  is  it  to  have  undergone  such  transformation; 
but  occasionally  this  is  not  true,  because  these  little  growths  may  un- 
dergo cystic  degeneration,  in  which  the  malignant  transformation  as- 
sumes the  type  of  colloid  cancer;  they  may  also  be  very  firm  from  inflam- 
matory or  fibroid  changes.  Transformation  can  not  therefore  be  predi- 
cated upon  consistence  alone. 

The  Pedicle. — This  is  formed  by  mucous  membrane,  fibrous  and 
submucous  tissue,  and  blood-vessels.  The  medium-sized  tumors  have 
longer  and  narrower  pedicles  than  the  small  or  large  ones.  The  very 
small  tumors  are  generally  sessile,  while  the  large  ones  are  attached  by 
thick,  short  pedicles  which  render  them  almost  so.     The  pedicles  are 


730  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

never  so  long  in  the  multiple  as  in  the  simple  variety.  When  trans- 
formation has  occurred  they  become  dense,  hard,  and  short. 

Condition  of  the  Mucous  Membrane. — There  is  always  more  or  less 
proctitis  or  colitis  along  with  this  condition.  Authors  differ  with  re- 
gard to  the  nature  of  this  change  in  the  mucous  membrane.  Desnos  says 
that  the  mucous  membrane  is  reddened  and  thickened,  while  Hauser 
states  that  it  is  injected  and  atrophied.  Quenu  and  Hartmann  explain 
this  by  saying  that  in  the  case  of  the  former  it  was  a  simple  undegen- 
erated  adenoma,  whereas  in  the  latter  they  were  all  cases  in  which 
carcinomatous  transformation  had  taken  place. 

The  pathological  examinations  of  Quenu  and  Landel  show  that  in 
the  whole  extent  of  the  colon,  and  far  away  from  the  carcinoma,  there 
was  an  atrophy  with  a  partial  destruction  of  the  glands  of  the  mucous 
membrane  and  infiltration  of  the  connective  tissue.  The  capillaries 
were  dilated  and  the  glandular  epithelium  had  almost  disappeared. 
Strange  to  say,  these  lesions  were  less  accentuated  in  the  neighborhood 
of  the  pol}'pi  themselves. 

In  the  cases  which  the  author  lias  examined  personally,  there  have 
always  appeared  clinical  evidences  of  hypertrophic  proctitis,  with  an 
increase  of  the  secretions  and  general  congestion  of  the  mucous  mem- 
brane. Until  he  had  read  the  report  of  the  authors  above  mentioned, 
he  had  supposed  this  catarrhal  condition  was  due  to  the  irritation  of 
the  mucous  membrane  by  the  neoplasms;  but,  accepting  their  report  as 
true,  one  must  conclude  that  the  changes  are  of  a  trophic  nature  rather 
than  due  to  any  mechanical  irritation. 

Symptoms. — The  s^Tnptoms  of  multiple  adenoma  of  the  rectum  may 
be  stated  in  four  words:  diarrhcsa,  haemorrhage,  pain,  and  exhaustion. 
The  diarrhoea,  which  is  at  first  slight,  is  always  anno\'ing  by  its  fre- 
quency, tenesmus,  and  griping  pains.  It  is  not  ordinarily  associated 
with  fever  or  constitutional  derangements,  but  it  is  uncontrollable  by 
any  remedy  short  of  complete  narcosis. 

Camphor,  tannic  acid,  opium  in  moderate  doses,  and  all  the  astrin- 
gent medicines  are  absolutely  powerless  to  control  this  condition. 

The  stools  are  small,  soft,  and  always  contain  mucus,  with  more  or 
less  fresh  or  decomposed  blood.  In  the  latter  case  the  color  is  black 
and  the  odor  very  disgusting. 

The  haemorrhages  are  at  first  very  slight,  occasionally  there  is  only 
a  tinge  of  blood  to  the  mucus,  but  as  the  disease  progresses  these  be- 
come more  marked,  and  the  stools  may  be  composed  almost  entirely 
of  blood  and  mucus.  Occasionally  mucus  alone  is  discharged,  slightly 
tinged  with  blood. 

The  amount  of  pain  which  the  patients  suffer  depends  upon  the 
location,  number,  and  size  of  the  adenomata.     Wliere  they  are  dis- 


BENIGN  TUMORS  OP  THE  RECTUM  T31 

tributed  throughout  the  colon,  tenesmus,  bearing-down  pain,  and  digest- 
ive disturbances  are  common.  Where  they  are  largely  confined  to  the 
rectum  and  sigmoid,  the  patients  do  not  suffer  very  much.  When  the 
tumors  grow  to  be  so  large  that  they  obstruct  the  passage  of  fsecal 
masses,  then  the  pain  becomes  more  severe.  This  is  not  only  due  to  the 
mechanical  obstruction,  but  sometimes  to  the  carcinomatous  change 
which  takes  place  in  these  neoplasms,  and  the  consequent  fibrous  narrow- 
ing of  the  caliber  of  the  gut. 

Prolapse  of  the  rectum  is  occasionally  associated  with  these  growths, 
and,  when  dragged  down  and  strangulated,  may  be  the  source  of  a  great 
deal  of  pain,  and  even  a  fatal  toxaemia.  The  constant  diarrhoea,  loss  of 
sleep,  loss  of  blood,  continuous  pain,  and  irregularities  of  digestion  in- 
evitably result  in  marked  ansemia  and  general  debility.  With  this 
develops  the  characteristic  cachexia  of  the  malignant  neoplasm  when 
the  tumors  undergo  carcinomatous  transformation;  and  death  is  the 
ultimate  result  of  the  disease  when  radical  operation  is  not  practised. 
■  Diagnosis. — The  diagnosis  of  multiple  adenoma  depends  upon  the 
subjective  symptoms,  together  with  the  local  manifestations  of  the  dis- 
ease. There  is  no  occasion  for  a  patient  with  a  protracted  and  in- 
veterate diarrhoea  to  be  treated  for  months  and  then  suddenly  told  that 
he  has  a  neoplasm  in  his  rectum. 

The  modern  treatment  of  diarrhoea,  when  it  persists  longer  than  a 
day  or  two,  demands  a  local  examination  of  the  rectum  and  sigmoid 
flexure.  Under  such  circumstances  adenoids  will  be  seen  or  felt  and 
the  diagnosis  made.  Where  there  are  more  than  one  or  two  in  the  rec- 
tum, associated  with  tenesmus  and  griping  pains,  diarrhoea  and  hgemor- 
rhages,  it  may  ordinarily  be  assumed  that  there  are  others  higher  up. 
By  the  use  of  the  pneumatic  sigmoidoscope  these  may  be  seen  up  to 
the  extent  of  the  sigmoid  flexure. 

Palpation  of  the  colon  will  sometimes  reveal  a  thickening,  but  it 
is  impossible  to  determine  by  this  means  the  height  to  which  the 
growths  extend.  It  is  important  to  determine  this  fact,  however,  and 
in  these  cases  one  need  not  hesitate  to  advise  immediate  laparotomy  for 
examination  of  the  colon  throughout  its  extent,  so  as  to  determine  the 
limitations  of  the  disease. 

Whether  or  not  the  tumors  have  undergone  malignant  transforma- 
tion can  be  told  by  the  induration,  which  is  apparent  to  the  touch  when 
the  tumor  is  within  reach,  by  the  odor  of  the  discharges,  or  by  the  gran- 
ular, ulcerative  condition  seen  through  the  proctoscope.  The  micro- 
scopic examination  of  a  section  of  a  tumor  is  the  most  reliable  evidence 
of  such  degeneration.  Unfortunately  the  fact  that  one  or  two  of  these 
tumors  does  not  show  any  malignant  transformation,  proves  nothing 
with  regard  to  the  others.     It  has  been  shown  by  Hauser  and  Quenu 


732  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

and  Landel  that  a  perfectly  benign  adenoma  may  be  almost  contigu- 
ous with  one  which  has  undergone  marked  epitheliomatous  transforma- 
tion. A  positive  negative  opinion,  therefore,  with  regard  to  malig- 
nancy can  never  be  given  in  these  cases.  The  chances  are  that  in  about 
3  out  of  4:  cases  of  multiple  adenoma  malignancy  occurs  in  some  of  the 
growths  sooner  or  later. 

In  an  examination  with  the  finger  one  may  feel  a  variety  of  growths 
ranging  from  a  small  pea-like  protuberance  to  a  well-developed  tumor. 
The  fact  that  the  growths  have  or  have  not  pedicles  can  not  materially 
influence  the  diagnosis.  In  their  earlier  stages  they  are  comparatively 
soft,  but,  being  inflamed,  or  having  undergone  malignant  transforma- 
tion, they  become  hard,  so  that  the  sense  of  touch,  so  far  as  these  charac- 
teristics are  concerned,  is  not  reliable. 

Where  the  tumors  are  large,  or  the  cancerous  degeneration  has  gone 
on  to  such  an  extent  as  to  cause  a  contracture  of  the  caliber  of  the  gut, 
one  will  find  stricture  or  rectal  occlusion. 

Whitehead  {op.  cit.)  lays  stress  upon  the  thickened,  sausage-like  feel 
of  the  sigmoid  flexure  in  these  conditions.  The  author  has  not  been 
able  to  observe  this  in  multiple  adenomata,  but  has  seen  it  a  number  of 
times  in  true  carcinoma  of  the  sigmoid  unassociated  with  them. 

Eotter  has  emi)loyed  exploratory  laparotomy  as  a  means  of  diagnosis; 
and  Sklifasowski  and  Lilienthal  have  made  artificial  ani  in  order  to 
determine  the  upper  limits  of  the  gi-owths.  From  Lilienthal's  case  it 
seems  that  where  such  a  course  is  followed,  the  artificial  anus  should 
be  made  in  the  right  inguinal  region  instead  of  the  left,  inasmuch  as 
the  growths,  if  they  extend  beyond  the  sigmoid  flexure,  are  likely  to  go 
well  into  the  ascending  and  transverse  colon. 

Patliologij. — The  tumors  are  seated,  as  a  rule,  upon  the  summit  of  the 
mucous  folds,  rarely  growing  from  the  grooves  between  them. 

Macroscopic  Appearances. — These  have  been  described  in  the  section 
on  conformation.  Quenu  and  Landel  state  that  they  sometimes  appear 
as  deformed,  hypertrophied  mucous  folds. 

Where  they  have  undergone  myxomatous  changes  they  appear  elastic 
and  gelatinous  to  the  touch. 

The  color  varies  from  a  dark  purplish-red  to  a  yellowish-gray,  but 
these  characteristics  can  not  be  observed  in  post-mortem  pathological 
specimens. 

Microscopic  Examination. — ^licroscopic  examination  shows  these 
growths  to  be  composed  of  hypertrophied  glands  and  connective  tissue 
covered  with  cylindrical  epithelium. 

Microscopic  Examination  7/i/  L.  Heitzmann.  —  ^'-  The  tumor  (Fig.  243)  is  composed 
of  a  myxomatous  connective  tissue  containing  a  large  number  of  lymph  corpuscles 
and  newly  formed  glands  of  varying  sizes.     These  glands  are  partly  of  the  tubular 


BENIGN  TUMORS   OF  THE  RECTUM 


733 


and  partly  of  the  acinous  variety,  lined  by  cuboidal  and  columnar  epithelia, 
arranged  mostly  in  a  single  layer,  though  in  some  places  stratified.  The  blood- 
vessels are  found  in  sqiall  numbers  only." 

In  some  of  the  specimens  examined  the  glands  were  very  much  elongated,  and 
their  lumen  greatly  enlarged.  Sometimes  they  vpere  transformed  into  actual 
cystic  cavities. 

Quenu  and  Hartmann  state  that  the  connective  tissue  is  of  the  loose, 
fibrillary  variety,  infiltrated  with  lymphatic  cells.  It  contains  smooth 
muscular  fibers, 
and  is  rich  in 
blood-vessels  which 
extend  to  the  per- 
iphery of  the  poly- 
pus. This  seem- 
ing disagreement 
with  regard  to  the 
vascular  supply  of 
these  growths  is 
dependent  upon 
the  actual  tumor 
examined.  Some  of 
them  have  a  large 
number  of  blood- 
vessels, while 
others  are  very 
scantily  supplied. 
In  Lilienthal's  case 
(Fig.  242)  the  pol- 
yps are  said  to  have 
been  composed  of 
hyperti'ophied  soli- 
tary follicles,  but 
this  appears  to  be 
unique. 

3£alig?iant 
Transformation.  — 
The  benign  epithe- 
lial tumors  of  the 

rectum  derive  an  immense  importance  from  their  great  tendency  to 
transformation  into  cylindrical  carcinoma.  In  two  of  the  cases  observed 
by  the  writer  this  change  had  already  occurred  at  the  time  of  the 
examination.  In  the  other  the  tumors  were  removed  from  the  rectum, 
and  three  months  later  the  patient  returned  with  a  marked  adeno-car- 


FiG.  243. — Lympho-adenoma.     (Magnified  200  diameters.) 

HH,  hypertrophied.  newly  formed  glands;  (7 C,  connective  tissue 
containing  numerous  lymph  corpuscles. 


734:  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

cinonia  at  the  site  of  oue  of  the  largest  growths.  In  the  43  cases  col- 
lected by  Quenii  and  Landel  {op.  cit.),  20  of  them  either  had  at  the 
time,  or  developed  afterward,  true  cylindrical  carcinoma.  While  many 
of  the  growths  contained  typical  adenomatous  tissue,  at  the  same  time 
they  presented  an  increase  in  the  epithelial  structures  with  the  irregular 
disposition  thereof  characteristic  of  carcinoma.  Hauser,  Bardenheuer, 
"Wulff,  and  Bickerstett  have  noted  these  changes  in  multiple  adenomata 
scattered  throughout  the  intestine  and  complicated  by  carcinomatous 
neoplasms.  It  is  an  established  fact  that  a  very  large  percentage  of 
the  cases  of  multiple  adenoma,  if  left  alone,  will  in  time  develop  malig- 
nant transformation  at  some  point  or  other.  The  fact  that  a  micro- 
scopic section  of  a  tumor  of  this  type  shows  a  benign  structure  is  some- 
times most  deceptive,  for  one  may  very  easily  obtain  the  specimen  from 
a  benign  growth,  whereas  the  adjacent  tumor  has  undergone  malignant 
transformation.  Even  in  the  same  growth  one  may  find  parts  of  it  per- 
fectly benign,  while  other  parts  have  undergone  epitheliomatous  trans- 
formation. Wulff  states  that  only  the  multiple  variety  of  adenomata 
undergo  this  transformation.  This  agrees  entirely  with  the  writer's 
experience.  There  are  no  authenticated  cases  on  record  where  a  single 
pedunculated,  adenoid  polypus  has  recurred  in  the  form  of  a  carcinoma. 

This  predisposition  to  malignant  change  along  with  the  diarrhoea, 
ha?morrhages,  and  exhausting  mucous  discharges  makes  this  t}'pe  of 
neoplasm  one  of  the  most  serious  with  which  we  have  to  deal.  The 
difhculty  of  entirely  eradicating  the  growths  when  scattered  throughout 
the  course  of  the  rectum,  sigmoid,  and  colon  renders  anything  short  of 
the  most  radical  and  extensive  operations  worse  than  useless.  The 
prognosis  in  all  these  cases  is  therefore  exceedingly  grave. 

Treatment. — The  treatment  of  multiple  adenoma  is  very  unsatisfac- 
tory. Diets  of  all  kinds  have  been  tried  without  any  particularly  good 
effect  upon  the  diarrhoea  and  the  discharges;  in  Lilienthal's  case  the 
meat  diet  seemed  to  have  a  very  bad  effect;  in  the  author's  cases  chopped 
meat  and  meat  broths,  together  with  a  small  amount  of  starchy  food, 
gave  the  patients  more  comfort  than  any  other;  the  milk  diet  has 
not  been  satisfactory,  as  a  rule;  in  some  cases  cereals  with  egg  albu- 
men reduce  the  number  of  stools. 

Medicines  are  utterly  unable  to  control  the  symptoms,  with  the 
exception  of  opium,  which,  if  given  in  large  enough  doses,  quiets  the 
pain  and  controls  the  diarrhoeal  movements  to  a  certain  extent.  Ergot 
and  tincture  of  cinnamon,  together  with  fluid  extract  of  hydrastis,  have 
a  beneficial  effect  upon  the  haemorrhages,  but  even  this  is  only  tem- 
porary. 

Czerny  (Quenu  and  Hartmann,  vol.  ii,  p.  76)  stated  that  the  com- 
bination of  opium  and  tannic  acid,  together  with  injections  of  salicyl- 


BENIGN  TUMORS  OF  THE  RECTUM  T35 

ated  oil^  gave  a  temporary  amelioration;  the  same  is  the  case  with  other 
astringent  irrigations. 

Surgical  procedures  have  proved  but  slightly  more  successful;  only 
temporary  benefits  have  been  derived  from  the  removal  of  the  adenomata 
from  the  rectum.  In  a  case  seen  with  Dr.  Ladinski,  from  time  to  time 
for  over  two  years,  the  growths  were  snared  off  from  the  surface  of  the 
bowel,  giving  considerable  relief  to  the  diarrhoea,  pain,  and  haemor- 
rhages; within  two  or  three  months,  however,  new  ones  developed,  and 
other  operations  became  necessary. 

The  operations  which  have  been  advised  consist  in  the  removal  of 
the  tumors  from  the  intestine  as  high  up  as  can  be  reached  by  ligature, 
cauterization,  and  radical  resection.  It  is  important  before  undertaking 
any  of  the  procedures  to  determine  if  possible  the  existence  of  malignant 
degeneration.  If  such  a  condition  exists,  no  operation  short  of  radical 
removal  of  the  affected  area  should  be  undertaken. 

When  the  tumors  are  confined  to  the  rectum  and  sigmoid,  they  may 
be  removed  through  the  cylindrical  proctoscope  and  with  a  wire  snare 
quite  as  effectually  as  by  the  more  serious  operations.  Gerster  in  2 
cases  did  posterior  proctotomy,  laying  the  rectum  open  as  high  up  as 
the  fourth  sacral  vertebra,  and  leaving  it  thus  open  while  from  time 
to  time  he  etherized  the  patient,  and  either  snared  or  burned  off  the 
numerous  tumors;  he  states  in  a  private  letter  to  the  author  that  in  both 
of  these  cases  he  succeeded  in  obtaining  a  cure  by  persistently  repeat- 
ing the  operation,  and  believes  this  is  the  only  means  of  doing  so. 
Malignant  transformation  did  not  occur  in  either  instance. 

Guyon  performed  a  like  operation,  removing  30  to  40  tumors  by 
ligating  the  pedicles;  his  patient,  however,  died  from  vomiting  and 
diarrhoea  shortly  afterward.  Eichet  by  the  use  of  a  rectal  speculum 
removed  between  80  and  100  polypi  by  seizing  them  with  forceps  and 
twisting  their  pedicles.  Considerable  hemorrhage  followed,  which  was 
checked  by  the  injection  of  ice-water,  and  later  by  the  application  of 
the  actual  cautery  to  the  stumps.  A  few  months  afterward  the  diar- 
rhoea and  hsemorrhage  returned,  and  the  patient  was  found  to  have 
developed  other  polypi  in  the  field  of  operation.  The  difficulty  of  apply- 
ing the  cautery  to  the  stumps  through  a  speculum  will  be  apparent  to 
all.  Whitehead,  by  applying  "his  method  of  operation  for  hsemor- 
rhoids,  succeeded  in  removing  along  with  the  mucous  membrane  of 
the  rectum  a  considerable  number  of  adenomata.  The  relief,  how- 
ever, was  only  partial  and  temporary.  Fochier  (Lyon  medicale,  1874) 
divided  the  mucous  membrane  of  the  rectum  into  five  portions,  dis- 
sected up  the  sections,  and  ligated  them  at  the  top,  thus  removing 
most  of  the  growths.  Within  a  year  he  had  to  intervene  a  number 
of  times,  adopting  the  methods  which  Kelsey,  Smith,  and  Whitehead 


736  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

have  more  recently  advised,  viz.,  curettage  and  cauterization  of  the 
tumors. 

Thomas  Smith  (8t.  Bartholomew's  Hospital  Report,  1887)  operated 
in  this  manner  five  times  within  the  space  of  as  many  years  to  control 
the  haemorrhages  in  one  of  these  cases;  the  patient  finally  died  from 
peritonitis,  having  developed  a  cancer  of  the  sigmoid  flexure. 

In  Ladinski's  case,  operations  by  excision  and  cauterization  had  been 
tried  before  he  began  the  method  of  snaring  off  the  tumors.  During 
the  two  years  which  he  observed  the  patient,  he  removed  at  different 
sittings  between  40  and  50  tumors  from  the  rectum  and  sigmoid  flexure. 
The  patient  is  still  alive  and  the  tumors  have  not  apparently  undergone 
malignant  transformation. 

Lilien that's  case  is  perhaps  the  most  remarkable  of  all  those  reported: 
A  young  woman  twenty-one  years  of  age  had  for  years  suffered  from 
diarrhwa,  haemorrhages,  and  the  passage  of  foul  mucus;  she  finally  be- 
came so  weak  and  ananuic  that  left  inguinal  colostomy  was  done  to  give 
the  pelvic  colon  and  rectum  rest.  At  this  operation  it  was  seen  that 
the  mucous  membrane  of  the  colon  was  covered  with  small  polypoid 
growths  extending  above  the  inguinal  anus.  Notwithstanding  this  fact, 
she  was  much  benefited,  the  haemorrhages  ceased,  and  the  artificial 
anus  was  closed.  It  was  only  a  short  time,  however,  before  all  her  old 
symptoms  returned,  and  it  became  necessary  to  do  something  for  her 
relief.  On  December  30,  1899,  he  performed  a  right  inguinal  colotomy, 
and  found  the  colon  at  this  height  covered  with  large  and  small  papillo- 
ma-like  excrescences,  which  the  pathologist,  Dr.  Mandlebaum,  described 
as  hypertrophied  solitary  follicles.  The  patient's  haemorrhages  almost 
entirely  ceased,  although  the  visible  mucous  membrane  seemed  to  be  un- 
changed. The  girl's  impatience  with  the  artificial  anus  and  the  fact 
that  all  her  symptoms  were  almost  sure  to  return  if  the  same  were 
closed,  determined  the  surgeon  to  exclude  the  facal  current  from  the 
entire  colon.  This  operation  he  did  on  March  0,  1900,  making  an  end- 
to-end  union  between  the  ileum  and  the  lower  portion  of  the  sigmoid 
flexure.  From  this  time  on  the  patient's  general  condition  was  clearly 
improved,  although  she  continued  to  have  from  9  to  15  stools  a  day. 

The  artificial  anus  upon  the  right  side  was  left  open  in  order  to  give 
vent  to  the  secretions  of  the  diseased  colon.  The  patient's  insistence 
upon  having  the  artificial  opening  closed,  and  willingness  to  assume  all 
risks  connected  with  the  operation,  led  him  to  attempt  the  removal  of 
the  entire  colon,  which  he  did  on  June  15,  1900.  After  various  com- 
plications of  a  most  interesting  nature,  and  associated  with  the  most 
wonderful  recuperative  power,  the  patient  recovered  from  this  most 
remarkable  and  skilful  operation. 

The  case  was  presented  at  the  New  York  Academy  of  ]\Iedicine, 


BENIGN  TUMORS  OF  THE  RECTUM  737 

January  l-i^  1901,  perfectly  well,  with  the  exception  of  a  small  sinus  in 
the  right  iliac  region,  which,  according  to  Lilienthal's  report,  entirely 
closed  hy  April  16th.  She  was  having  then  two  moyements  a  day; 
the  stools  were  ordinarily  semisolid,  but  sometimes  well  formed.  The 
appearance  (Fig.  21:2),  the  histological  findings,  and  the  results  in  this 
case  are  unique. 

Kelsey  states,  after  having  operated  nine  times  upon  one  patient  by 
raclage  and  tearing  away  of  the  growths,  that  the  only  method  which 
offers  any  prospect  of  a  cure  is  a  radical  excision  of  the  affected  area. 

Where  the  tumors  are  limited  to  the  rectum  or  to  any  single  portion 
of  the  colon,  this  may  be  accomplished,  and  even  as  in  the  case  of 
Lilienthal,  the  whole  organ  may  be  removed,  but  it  is  a  desperate  resort. 
Where  malignant  transformation  has  taken  place,  this  method  certainly 
offers  the  only  hope.  It  is  useless,  however,  to  attempt  to  remove  one 
section  of  the  gut,  even  if  it  contain  a  well-marked  carcinoma,  and 
leave  a  greater  or  less  area  above  it  affected  by  the  adenomata.  The 
diarrhoea,  ha?morrhages,  and  discharge  from  these  will  almost  surely  pre- 
vent the  union  of  the  segments,  and  even  if  this  should  take  place  the 
recurrence  of  the  epithelioma  in  them  is  almost  inevitable.  If  the 
epitheliomatous  change  has  taken  place  in  the  rectum  or  sigmoid  flexure, 
an  artificial  anus  may  be  made  upon  the  left  side  and  all  of  the  gut 
below  this  portion  removed  after  the  method  of  AVeir  or  Quenu.  By 
such  means  the  dangers  of  non-union  between  the  two  ends  of  the  gut 
may  be  averted,  and  carcinomatous  transformation  in  the  parts  above 
be  indefinitely  deferred. 

As  a  palliative  means,  either  an  artificial  anus  upon  the  right  side 
may  be  made,  thus  relieving  the  colon  from  the  irritation  of  the  fsecal 
passages,  or,  what  is  better  still,  the  ftecal  current  may  be  diverted 
through  anastomosis  between  the  ileum  and  the  rectum,  as  was  done 
by  Lilienthal,  Eotter,  and  Holtmann.  In  the  latter  2  cases  the  affected 
area  was  not  removed,  and  both  patients  died — one  from  '"  cachexia  " 
and  the  other  from  peritonitis.  Quenu  and  Hartmann  were  more  suc- 
cessful in  a  like  case  in  which  they  made  an  anastomosis  between  the 
ileum  and  the  last  loop  of  the  sigmoid  flexure.  This  patient  was  greatly 
improved  in  health  at  the  time  of  the  report.  The  operation,  however, 
does  not  aim  at  a  cure,  and  can  only  result  in  an  amelioration  of  the 
patient's  symptoms.  In  Lilienthal's  case  the  tumors  showed  no  atrophj^ 
or  decrease  after  the  fgecal  current  had  been  diverted;  it  may  obviate 
the  carcinomatous  transformation  by  the  prevention  of  irritation  from 
the  fsecal  passages.  When  such  an  operation  is  undertaken,  the  anasto- 
mosis should  be  made  in  the  lower  loop  of  the  sigmoid  flexure  after 
the  rectum  has  been  practically  cleared  of  the  adenomata.  Wlien  the 
disease  is  limited  to  the  rectum,.  Gerster's  method  appears  to  offer  the 
47 


738  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

best  chance  for  cure;  otherwise  excision  or  entero-anastomosis  should 
be  done. 

Villous  Tumor:  Papilloma. — Under  the  title  "  villous  tumor,"  Quain 
and  Allingham  have  described  a  neoplasm  consisting  of  a  "  lobulated, 
spongy  mass  with  long,  villous-like  groups  studding  its  surface."  The 
same  growths  have  been  described  by  different  authors  under  different 
names:  Glandular  Papillomas  (Gosselin),  Villous  Cancer  (Eokitansky), 
Papilloma  (Yirchow),  and  Papillary  Tumors  (Forster).  They  are  said 
to  resemble  very  much  the  tumors  of  the  same  name  found  in  the 
bladder,  although  the  ends  of  tlie  villi  are  generally  more  blunt  or  club- 
shaped  (Plate  Y,  Fig.  2).  They  arise  from  the  superficial  surface  of  the 
mucous  membrane  of  the  intestine,  and  are  attached  by  a  broad  base 
rather  than  by  a  pedicle;  they  may  occasionally  become  pedunculated, 
the  broad,  flat  attachment  to  the  mucous  membrane  being  dragged  out 
to  the  extent  of  2  or  3  inches.  Allingham  states  that  this  pedicle  is 
apparent  rather  than  real;  that  the  tumors  grow  from  the  surface  of 
the  gut,  and  by  their  weight  drag  the  folds  of  the  bowel  down  and  give 
rise  to  the  appearance  of  a  pedicle.  They  ordinarily  grow  well  up 
within  the  bowel,  and  more  frequently  from  the  posterior  wall,  but 
they  have  been  seen  both  on  the  anterior  and  lateral  walls  of  the  gut. 
When  they  arise  from  that  portion  of  the  intestine  covered  by  peri- 
tonaeum and  become  elongated  or  dragged  down,  it  is  possible  for  them 
to  drag  along  with  them  a  fold  of  this  membrane,  thus  forming  a  sort 
of  cul-de-sac  in  the  wall  of  the  gut  (Allingham,  op.  cit.,  1896,  p.  465). 
This  fact  appears  to  be  inconsistent  with  the  view  taken  by  this  author 
with  regard  to  the  origin  of  the  growth  upon  the  superficial  surface  of 
the  mucous  membrane;  if  the  submucosa  and  muscular  wall  of  the  in- 
testine are  not  involved  in  the  growth,  it  is  difficult  to  understand 
how  it  can  drag  down  a  fold  or  cul-de-sac  of  the  peritoneum.  The 
precaution,  however,  which  he  suggests  with  regard  to  the  possibility 
of  opening  the  peritoneal  pouch  by  cutting  off  one  of  these  tumors  is 
well  worth  remembering. 

These  tumors  are  exceedingly  rare;  Allingham  has  collected  in  all 
30  cases,  17  being  in  his  o^vn  practice;  Quenu  and  Landel  have  added 
7  cases  to  this  number,  4  of  which  they  have  observed  personally,  and 
have  described  minutely  (Ee^'ue  de  gynec.  et  de  chirur.  abdom.,  Febru- 
ary, 1899)  under  the  name  of  villous  tumors  or  superficial  vegetating 
epitheliomas  of  the  rectum.  It  is  to  these  authors  that  we  are  in- 
debted for  a  pathological  study  of  these  neoplasms. 

They  make  a  very  clear  distinction  between  these  vegetating,  super- 
ficial growths  and  those  cases  of  secondary  vegetations  which  develop 
at  a  late  period  upon  the  surface  of  true  cancers.  The  cut  (Fig.  244) 
is  an  excellent  illustration  of  the  appearance  of  these  growths,  and  gives 


PLATE  V, 


FIBROID  POLYPUS 


PAPILLOMA 


CONDYLOMA,   FIBROID,  AND    PAPILLOMA 


BENIGN  TUMORS  OF  THE  RECTUM 


739 


a  clear  idea  of  the  distinction  between  them  and  the  cylindrical  epi- 
thelioma as  it  first  develops  in  the  rectum.     In  one  case  they  observed 
a  villous  tumor  compli- 
cated by  tuberculous  ul-  ^ 
cerations  below,  a  colloid 

cancer    above,    together  ^  \ 

with  a  recto-vaginal  fis- 
tula, and  in  which  an 
ablation  of  the  rectum 
was  made  and  a  cure  re- 
sulted. 

The  macroscopic  ap- 
pearance, as  described  by 
these  authors,  differs  very 
little  from  that  given  by 
Allingham  and  Quain. 
The  tumors  are  red  in 
appearance,  soft  and  vel- 
vety to  the  touch,  and 
vary  in  size  from  that 
of  a  pea  to  a  small  egg, 
although  they  are  not 
ordinarily  spherical  but 
plaque  -  like;     they     are 

composed  of  large  numbers  of  villi  or  papillae,  free  at  their  surfaces  but 
conjoined  at  the  base,  thus  forming  a  sort  of  lobulated  tumor. 

The  French  authors  state  that  in  each  lobe  the  papillae  group  them- 
selves anew  in  order  to  constitute  lobules  of  a  second  or  third  order; 
that  if  the  tumor  be  plunged  into  water  the  different  lobules  and  papil- 
lae float,  and  their  divisions  and  subdivisions  are  easily  perceptible. 

These  tumors  may  become  very  large;  Allingham  states  that  one  of 
those  which  he  observed  was  as  large  as  a  foetal  head,  and  Cripps  has 
reported  one  as  large  as  his  fist.  Ordinarily,  however,  they  do  not 
exceed  that  of  an  English  walnut.  Hauser,  quoted  by  Quenu  and  Hart- 
mann,  states  that  these  neoplasms  are  seated  exclusively  in  the  mucous 
membrane  or  in  the  superficial  layers  of  the  submucosa;  that  they  are 
formed  of  a  greater  or  less  number  of  excrescences,  red,  and  of  a  medul- 
lary consistence.  The  French  authors,  however,  state  that  they  have 
never  found  the  tumor  to  go  deeper  than  the  muscularis  mucosa.  While 
Hauser  states  that  the  tumors  are  ordinarily  pedunculated,  the  French 
writers  and  Allingham  claim  that  they  are  more  frequently  sessile,  and 
that  the  villosities  which  constitute  the  tumor  are  directly  implanted 
upon  the  wall  of  the  intestine  and  united  at  their  base.     They  say: 


Mi    -  >  iJ  I      L-     1  L  \I()li  Utbo\t;  AND  CiLI\DKIC^.L    EpI- 

THELioiiA  (below).     (Quenu  and  Hartmann.) 


740 


THE   ANUS,   RECTUM,   AND   PELVIC   COLON 


Fig.  245. — Schematic  Illustration  of 
Eectal  Papilloma. 


"  The  soft  consistence  of  these  tumors,  their  superficial  relation  to  the 
intestinal  mucosa,  and  their  peculiar  papillary  structure  constitute,  from 

a  macroscopic  point  of  view,  the 
fundamental  characters  which  per- 
mit us  to  distinguish  them  from 
all  other  tumors." 

The  schematic  cut,  taken  from 
Quenu  and  Hartmann  (Fig.  245), 
represents  the  pedunculated  form 
of  these  growths.  The  pedicle  is 
composed  of  connective  tissue,  small 
vessels,  smooth  muscular  fibers,  to- 
gether with  some  migratory  cells 
and  young  connective-tissue  cells. 
It  is  surrounded  by  a  superficial  fold 
consisting  of  interstitial  tissue  en- 
closing tubes  of  glandular  appear- 
ance; the  surface  of  the  tumor  is 
covered  with  cylindrical  epithelium;  the  interstitial  portion  is  composed 
of  fibrous  tissue  of  new  growth,  constituting  a  sort  of  reticulum,  and 
containing  a  large  number  of  migratory  cells  and  young  connective- 
tissue  cells,  together  with  numerous  small  vessels  (Fig.  246).  Accord- 
ing to  Heitzmann,  the  structure  of  these  growths  is  as  follows: 

"  The  tumor  consists  of  a  delicate  connective-tissue  stroma  rich  in 
blood-vessels  and  infiltrated  with  partly  round  and  partly  spindle-shaped 
lymph  or  inflammatory  corpuscles.  The  surface  is  markedly  papillary 
in  nature,  and  the  epithelial  covering  consists  of  either  a  single  la3'er 
of  columnar  or  comparatively  thin  layer  of  stratified  cuboidal  cells." 

Quenu  and  Landel  state  that  in  the  connective  tissue  there  are  in- 
cluded a  large  number  of  epithelial  tubes  extending  to  the  extremities 
of  the  papilliform  prolongations.  These  tubes  are  more  or  less  ramified 
and  irregular,  and  one  recognizes  in  them  some  small  cystic  cavities 
lined  with  epithelium. 

The  alterations  of  the  epithelium,  according  to  them,  present  charac- 
teristics resembling  both  the  adenoma  and  the  cylindrical  epithelioma. 
They  note  a  gradual  change  of  the  epithelium  in  going  from  the  base 
toward  the  periphery  of  the  lobules,  from  an  adenomatous  type  to  a 
cylindrical  epitheliomatous  t}"pe,  and  also  a  predominance  in  a  well- 
established  tumor  of  the  epitheliomatous  tjipe  of  these  cells.  This 
change  in  t}^e  consists  in  a  gradual  decrease  in  the  mucous  cupules  and 
an  increase  in  the  granulation  of  the  protoplasm,  together  with  other 
more  obscure  changes,  such  as  an  increase  in  the  reaction  to  coloring 
agents,  in  richness  of  chromatine,  etc. 


BENIGN  TUMORS  OF   THE   RECTUM 


Y41 


Their  conclusions,  after  these  extensive  studies,  is  expressed  in  the 
following  summary:  "  The  villous  tumors  are,  from  a  histological  point 
of  view,  cylindrical  epitheliomas  presenting  a  remarkable  tendency  to 
maintain  in  a  greater  or  less  degree  the  primitive  characters  of  the 
elements  from  which  they  are  derived.  This  tendency  manifests  itself 
in  the  interstitial  tissue,  of  which  the  primitive  structure  is  not  sensibly 
modified,  and  in  the  epithelial  tissue  which  embraces  a  mixture  of  the 
epitheliomatous  and  glandular  elements,  more  or  less  normal,  with  nu- 
merous forms  in  transition  between  these  two  t}'p)es." 

Etiology  and  Development. — The  etiology  of  these  growths  is  not  un- 
derstood. So  far  as  age  is  concerned,  it  appears  to  be  one  of  adult  and 
advanced  life.  In  16  cases,  13  were  found  in  patients  above  the  age  of 
forty  years.     In  3  cases  it  was  found  below  the  age  of  thirty  years. 


Fig.  246. — Papillojia  of  Eectum.     (Magnified  200  diameters.) 

PP,  papilla  covered  by  coluronar  and  partly  euboidal  epithelia ;  T  T,  connective  tissue  infiltrated 
with  lymph  and  inflammatory  corpuscles ;  5,  blood-vessels. 

There  seems  to  be  no  predominance  in  either  sex;  8  have  been  observed 
in  men  and  8  in  women  (Quenu  and  Hartmann,  op.  cit.,  p.  107). 

As  to  the  previous  conditions  causing  the  development  of  these 
tumors,  little  can  be  said.  Constipation  is  the  only  habitual  condition. 
The  loss  of  blood  and  the  existence  of  hEemorrhoids  has  been  stated  by 
Allingham  to  have  existed  in  a  number  of  patients,  but  no  connection 
can  be  traced  between  these  and  the  production  of  the  growths.  Some 
cases,  even  though  the  tumors  have  been  discovered  late  in  life,  give 
the  history  of  having  had  a  loss  of  blood  for  many  years,  and  the  patients. 


Y42        THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

supposing  they  suffered  from  ordinary  internal  hasniorrhoids,  gave  the 
matter  little  concern.  Inasmuch  as  the  liEemorrhoidal  development  was 
not  marked  in  any  of  these  instances,  it  seems  fair  to  presume  that  the 
blood  came  from  the  tumors  which  had  existed  for  much  longer  periods 
than  was  supposed.  No  germs  or  bacteria  have  been  discovered  in  the 
growths,  although  upon  the  surface  and  in  the  lacunae  numerous  leuco- 
cytes have  been  found,  together  with  colon  bacilli  and  the  various  bac- 
teria of  the  intestinal  canal. 

Symptoms. — The  first  and  most  prominent  symptom  connected  with 
this  type  of  the  growth  is  the  frequent  and  abundant  discharge  of  a 
peculiar  gluey  mucus  resembling  the  white  of  an  egg,  but  staining  the 
linen  faintly  yellow. 

While  there  is  a  condition  of  costiveness,  there  is  a  frequent  desire 
to  defecate,  which  results  only  in  the  passage  of  mucous  discharge, 
Allingham  states  that  this  discharge  is  simply  an  excessive  secretion 
of  the  normal  mucous  membrane  of  the  rectum  due  to  the  proliferation 
of  the  villi  and  mucus-producing  cells.  He  considers  it  the  most  im- 
portant s}Tnptom  of  the  disease.  The  mucus  escapes  involuntarily  at 
times,  and  it  is  impossible  in  many  cases  for  the  patients  to  keep  their 
clothing  clean. 

This  loss  of  mucus  is  weakening  and  debilitating,  and  shows  itself 
in  the  pallor  and  loss  of  flesh  in  the  patient,  just  as  excessive  purulent 
discharges  do. 

Haemorrhages  from  these  growths  are  very  variable.  Occasionally 
they  come  on  only  once  in  long  periods  of  time,  in  others  there  is  a 
constant  oozing,  and  the  mucous  discharge  is  tinged  with  blood.  Or- 
dinarily the  blood  is  fresh,  and  may  continue  to  drip  and  ooze  for  some 
time  after  stool.  At  other  times  it  is  clotted,  or  black  and  decomposed. 
Large  haemorrhages  may  occur  from  these  growths,  exsanguinating  the 
patient,  and  bringing  on  extreme  anamia  or  syncope. 

In  one  case  described  by  Cripps  {np.  cit.,  p.  301),  the  patient  only 
noticed  that  she  had  a  free,  watery  discharge  from  the  bowel,  together 
with  a  sensation  of  the  bowel's  not  being  completely  relieved.  Careful 
examination,  however,  proved  this  discharge  to  be  a  very  thin  mucus, 
which  rapidly  decreased  when  the  patient  was  kept  in  the  recumbent 
posture.  The  discharge  came  from  a  large  villous  polyp  attached  about 
3^  inches  from  the  anus. 

Constipation  has  been  mentioned  as  a  typical  S}Tnptom  or  prodrome 
of  the  condition.  In  the  cases  reported  there  seems  to  be  no  fixed 
rule  concerning  this,  many  of  them  suffering  from  constipation  and 
others  from  diarrhoea.  In  the  case  referred  to  tlie  author  by  Dr.  Teague, 
of  Xorth  Carolina,  diarrhcea,  tenesmus,  and  recurrent  haemorrhages 
were  the  important  symptoms,  together  with  a  cachexia  indicating  ma- 


BENIGN  TUMORS  OF  THE  RECTUM  743 

lignant  disease.  This  case  is  apparently  well  four  years  after  the  re- 
moval of  the  tumors.  Two  other  cases,  in  which  constipation  was  marked, 
died  from  carcinoma  after  the  papillomata  were  removed. 

Quenu  and  Allingham  state  that  the  descent  or  protrusion  of  the 
tumor  when  the  bowels  move,  or  even  at  other  times,  is  one  of  the  prom- 
inent symptoms;  but  in  examining  the  reported  cases,  it  is  found  that 
this  does  not  take  place  in  anything  like  the  majority  of  them.  The 
growths  develop  usually  at  a  considerable  height  from  the  anus,  the 
pedicles  are  not  long,  and  therefore  protrusion  must  be  an  exception 
rather  than  the  rule.  The  authors  quoted  state  when  this  occurs  it  is 
difficult  to  replace,  and  that  it  is  during  such  a  protrusion  that  the  ex- 
aggerated hEemorrhages  occur.  In  one  case  reported  by  Allingham,  a 
haemorrhage  producing  a  syncope  occurred  under  these  conditions,  but 
immediately  ceased  when  the  tumor  was  reduced. 

Pain  is  not  at  all  a  prominent  symptom.  The  patient's  chief  com- 
plaint is  concerning  the  haemorrhage  and  mucous  discharges,  together 
with  a  feeling  of  incomplete  action  of  the  bowels,  a  fulness  of  the 
pelvis,  and  weight  or  aching  in  the  sacral  region. 

The  constitutional  s}Tnptoms  are  dependent  upon  these  discharges 
and  hgemorrhages,  together  with  the  irregular  action  of  the  bowels;  they 
consist  in  a  loss  of  flesh  and  appetite,  digestive  derangements,  pallor, 
anaemia,  and  sometimes  actual  syncope  after  the  hemorrhages  or  diar- 
rhoeal  attacks. 

Mechanical  interference  with  the  passages  may  result  in  f seal  impac- 
tion, inducing  tenesmus,  flatulence,  swelling  of  the  abdomen,  and  all 
the  symptoms  due  to  obstruction,  but  such  accidents  are  exceedingly 
rare. 

To  the  touch  the  tumors  present  a  soft,  slimy,  velvet-like  feel,  slight- 
ly elastic,  and  particularly  wanting  in  that  solidity  which  characterizes 
adenoma.  The  end  of  the  finger  can  be  insinuated  between  the  lobules, 
and  a  villous-like  feel  can  be  made  out. 

If  the  tumor  has  been  dragged  down  and  its  attachment  to  the  wall 
of  the  g-ut  can  be  reached,  a  broad,  flat  fold  may  be  made  out.  The 
surface  of  this  pedicle  differs  from  that  of  the  tumor  itself  in  that 
it  is  soft,  smooth,  and  has  none  of  the  villous-like  characteristics  of 
the  tumor. 

A  point  to  which  Quenu  and  Landel  call  particular  attention  in 
regard  to  these  pedicles  is  that,  even  at  the  point  of  their  insertion  into 
the  rectal  wall,  there  is  absolutely  no  induration,  and  the  mucous  mem- 
brane preserves  its  suppleness  and  normal  constituency.  It  is  this  one 
point  which  distinguishes  these  growths  clinically  from  cylindrical  epi- 
thelioma, and  gives  them  any  right  to  be  classed  among  the  benign  neo- 
plasms of  the  rectum. 


744 


THE  ANUS,   RECTUM,  AND  PELVIC  COLON 


Through  the  speculum  they  appear  as  bright  or  dark-red  mamillated 
masses,  granular  in  appearance,  and  composed  of  lobules  separated  by 
deep  sulci.  In  some  cases  their  surface  appears  as  a  sort  of  shaggy  efflores- 
cence, resembling  more  or  less  closely  the  villous  polypi  of  the  bladder, 
but  ordinarily  the  branches  have  club-shaped  extremities  (Fig.  247). 

Diagnosis. — Papilloma  or  villous  tumor  may  be  confounded  with 
mucous  polypi,  myxomata  or  fibromata  of  the  rectum.  The  distinction 
between  them  and  mucous  polypi  lies  chiefly  in  the  fact  that  the  latter 
are  found  almost  entirely  in  children,  while  papillomata  are  nearly  al- 
ways seen  in  elderly  people;  the  pedicles  of  the  former  are  much  smaller 

than  those  of  the  latter, 
while  the  discharge  of 
mucus  and  blood  from  pa- 
pillomata is  much  greater 
than  that  from  the  poly- 
pi. The  consistence  of 
papilloma  is  much  less 
marked  than  that  of  fibro- 
ma, while  its  peduncula- 
tion  is  also  less  marked. 
Papillomata  and  multiple 
adenomata,  while  they 
both  occur  in  elderly  peo- 
ple, may  be  distinguished 
by  the  fact  that  the  ade- 
nomata are  firmer  to  the 
touch,  and  much  more  nu- 
merous as  a  rule.  The 
surface  of  the  papilloma 
is  more  irregular  and  lobulated;  and,  while  there  is  a  persistent  gluey 
mucous  discharge  in  these  cases,  there  is  never  that  uncontrollable  diar- 
rhoea, with  muco-purulent  dejections,  such  as  is  seen  in  multiple  adeno- 
mata. 

The  distinction  between  these  tumors  and  the  vegetating  form  of 
carcinoma  lies  in  the  fact  that  there  is  no  induration  at  the  point  of 
their  implantation  in  the  mucous  membrane,  and  they  are  much  less 
friable  than  the  carcinoma. 

Macroscopically  and  microscopically  they  resemble  very  closely  the 
adeno-carcinomas  of  the  rectum.  Allingham  has  reported  their  recur- 
rence after  removal  in  the  shape  of  carcinoma,  and  Quenu  and  Landel 
claim  to  have  observed  the  transformation  of  one  of  these  tumors  into 
a  malignant  neoplasm  without  any  surgical  interference  having  taken 
place. 


Fig.  247. — Villous  Polyp  of  the  Rectum  (Ball). 


BENIGN  TUMORS  OF  THE  RECTUM  745 

The  following  histological  report  of  a  ease  which  gave  every  clinical 
appearance  of  being  benign  papilloma  is  corroborative  of  the  theory  of 
Hartmann  and  Quenu,  that  these  growths  are  transformed  into  malignant 
neoplasms,  and  nothing  short  of  complete  removal  and  microscopical 
examination  of  the  entire  field  can  eliminate  the  possibility  of  such  a 
change  in  any  given  case. 

The  macroscopic  appearance  of  this  growth  is  well  delineated  in 
Plate  VII.  Through  the  speculum  the  tumors  gave  every  appearance 
of  being  benign.  The  constriction  and  induration  of  the  gut  above 
the  base  of  the  tumors,  however,  led  to  a  clinical  diagnosis  of  papil- 
loma and  carcinoma  adjacent  to  each  other.  Microscopic  examination, 
however,  showed  that  the  supposed  papilloma  had  undergone  malignant 
transformation. 

Histological  Eeport  ty  Louis  Heitzmann. — "The  pedunculated  growths  in  the 
lower  portion  of  the  tumor  were  found  to  consist  in  many  places  of  connective 
tissue,  partly  fibrous,  partly  myxomatous  in  character,  filled  to  a  varying  degree 
with  lymph  and  inflammatory  corpuscles,  generally  quite  abundant  and  coarsely 
granular.  Besides  these  groups,  individual,  large,  irregular,  coarsely  granular 
multinuclear  epithelia  are  found, 

"  The  blood-vessels  are  quite  abundant.  In  a  number  of  sections,  a  few  large, 
irregular,  convoluted  glands  are  present,  the  original  layers  of  polyhedral  nucleated 
formations  filling  the  calibers  to  a  greater  or  less  degree. 

"  The  diagnosis  of  these  growths  is  adenoid  cancer,  changing  to  medullary,  in 
all  probability  originally  benign. 

"  Specimens  from  above  these  tumors  show  connective  tissue  greatly  infiltrated 
with  medullary  corpuscles,  while  in  the  upper  portions  there  are  numerous  irreg- 
ular, coarsely  granular,  multinuclear  epithelia  of  various  sizes  arranged  in  nests 
and  tracts  as  well  as  irregularly  scattered,  and  a  large  number  of  inflammatory 
corpuscles  crowded  with  micro-organisms.  The  connective  tissue  here  is  generally 
scanty. 

"  The  diagnosis  of  this  portion  of  the  tumor  is  medullary  cancer  in  a  state  of 
ulceration  and  of  a  very  malignant  type." 

This  tumor  was  seen  three  months  previous  to  operation,  and  there 
were  no  clinical  evidences  of  malignant  transformation  at  that  time. 

Treatment. — These  tumors,  while  exceedingly  rare,  demand  when 
once  diagnosed  a  radical  and  prompt  removal.  The  possibility  of  their 
transformation  into  malignant  neoplasms,  the  certainty  of  their  gradual 
increase  in  size,  and  the  debilitating  effect  of  the  mucous  and  hsemor- 
rhagic  discharges  from  them,  together  with  their  mechanical  obstruc- 
tion to  the  normal  action  of  the  bowels,  and  the  reflex  irritations  which 
they  produce,  render  such  a  course  mandatory. 

The  fact  that  the  tumors  may  sometimes  be  spontaneously  torn  from 
their  attachments  and  cast  off  (Allingham)  should  never  be  relied  upon, 
or  even  mentioned,  to  excite  an  illusory  hope  in  the  mind  of  the  patient. 

Radical  surgical  interference  is  the  only  rational  means  of  dealing 


746  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

with  such  growths.  Any  compromising  or  palliative  treatment,  such  as 
cauterizing  with  chemical  cauterants,  or  even  the  actual  cautery,  will 
only  result  in  temporary  benefit  and  eventual  injury  to  the  patient. 
Recognizing  the  fact,  as  stated  by  Allingham  and  corroborated  by  Cripps 
and  Quenu  and  Landel,  that  these  tumors  may  drag  down  into  their 
pedicles  or  bases  little  pouches  of  the  peritonaeum,  one  should  be  very 
careful  in  their  removal  that  a  method  is  employed  which  will  absolutely 
prevent  the  opening  of  such  a  cul-de-sac. 

Where  the  pedicle  is  of  moderate  size  it  may  be  encircled  by  a  strong 
ligature  and  thus  tied;  the  constriction  of  the  ligature  closing  the  peri- 
toneal sac,  if  such  should  exist,  will  cause  adhesion  between  its  walls, 
and  thus  prevent  an  opening  being  made  after  the  tumor  is  cut  off. 
This  method  of  applying  the  ligature,  however,  is  somewhat  dangerous, 
owing  to  the  fact  that  it  may  slip  off  in  a  short  time  after  it  is  applied, 
and  thus  allow  the  peritoneal  cavity  to  open,  or  permit  serious  hemor- 
rhage. In  order  to  avoid  this,  Quenu  and  Hartmann  have  advised  that 
the  pedicle  be  transfixed  and  then  tied  upon  either  side.  This  is  a 
wise  precaution,  and  would  be  perfectly  acceptable  were  it  not  for  the 
fact  that  the  needle  passing  through  the  mucous  membrane  must  also 
pass  through  the  peritoneal  sac  and  thus  may  carry  infection  into  that 
cavity.  Moreover,  the  threads  passing  through  the  pedicle  and  through 
the  sac,  if  such  be  included  in  the  pedicle,  act  as  a  sort  of  wick  for  the 
first  few  hours;  and  if  there  be  septic  material  in  the  rectum  will  carry 
it  into  the  peritoneal  cavity,  and  may  thus  set  up  a  peritonitis. 

It  seems  better,  therefore,  where  the  tumor  is  of  small  size  to  tie  the 
pedicle  tightly  by  the  ligature  and  leave  the  tumor  in  situ  until  it 
sloughs  away;  by  this  procedure  there  is  little  danger  of  the  ligature 
slipping  off. 

Where  the  pedicle  is  broad  and  large,  and  the  tumor  is  obstructing 
the  lumen  of  the  gut,  this  method  is  not  altogether  satisfactory.  It 
is  important  in  such  cases  that  the  tumor  be  removed  at  once.  One 
should  therefore  take  every  antiseptic  precaution  and  apply  the  trans- 
fixion method,  taking  the  chances  of  infection  as  mentioned  above.  In- 
stead of  passing  the  ligature  through  the  center  of  the  pedicle,  it  may 
be  passed  through  the  mucous  membrane  at  each  border,  and  tied  as  a 
mattress  suture.  One  might  also  apply  hysterectomy  forceps  to  the 
stump  in  such  cases,  leaving  them  on  for  two  or  three  days. 

Where  the  tumor  has  no  pedicle,  and  its  base  is  as  large  as  its  ex- 
tremity, it  should  be  excised,  and  the  edges  of  the  wound  sutured  to- 
gether with  catgut  sutures. 

In  the  case  described  by  Cripps  {op.  cit.,  p.  303)  the  pedicle  was 
very  broad.  He  transfixed  and  tied  it  at  several  points  in  order  to 
perfectly  control  the  haemorrhage,  taking  the  chances  of  infecting  the 


BENIGN  TUMORS   OF   THE   RECTUM  T4Y 

peritoneal  pouch  by  the  needle  and  the  wick-like  action  of  the  ligature. 
As  these  gro\rths  are  not  multiple,  resection  of  the  gut  is  rarely  if  ever 
called  for  until  transformation  is  observed. 

Cystoma. — This  general  term,  indicating  cystic  neoplasms,  embraces, 
so  far  as  the  rectum  is  concerned,  all  those  tumors  which  have  undergone 
cystic  degeneration,  as  well  as  dermoids  and  hydatids. 

Eeference  has  been  made  to  the  cystic  degeneration  of  adenomas, 
fibromas,  and  other  neoplasms  of  the  rectum;  in  all  of  these  cases  the 
cyst  is  of  secondary  consideration,  the  true  histological  nature  of  the 
tumor  being  preserved  more  or  less  in  the  walls  of  the  cyst  and  the 
solid  portions  of  the  growth. 

Simple  Cysts. — These  growths  are  very  rare  in  the  rectum.  Prideaux 
(London  Lancet,  August  18,  1883)  has  recorded  a  very  interesting  case. 
A  woman  who  had  suffered  from  a  very  difficult  labor  complained  of  in- 
tense pain  in  the  pelvic  region;  her  abdomen  became  distended  and 
tympanitic,  and  she  exliibited  all  the  signs  of  intestinal  obstruction; 
she  described  herself  as  unable  to  pass  gas  on  account  of  something 
closing  up  the  rectum. 

Digital  examination  of  this  organ  elicited  a  tumor  almost  as  large  as 
a  foetal  head  resting  low  down  in  the  ampulla  of  the  rectum.  It  was 
soft  and  elastic,  and  gave  the  impression  of  an  intussuscepted  intestine. 
"  The  tumor  was  not  covered  by  mucous  membrane,  its  surface  being 
rough  and  much  injected." 

It  was  dragged  down  and  out  of  the  anus,  and  was  found  to  be  at- 
tached by  a  pedicle  6  inches  in  length,  which  was  tied  in  two  places  and 
cut  off.  The  tumor  itself  contained  half  a  pint  of  albuminous  fluid,  and 
its  walls  measured  from  -^  to  ^  of  an  inch  in  thickness.  'No  pathological 
examination  was  made  to  determine  the  histological  nature  of  the 
growth.  The  external  covering  having  been  described  as  different  from 
mucous  membrane,  one  would  have  expected  to  find  evidences  of  a  der- 
moid cyst,  but  from  the  description  one  can  only  conclude  that  it  was 
a  simple  cyst  in  which  the  characteristic  elements  of  the  mucous  mem- 
brane had  been  destroyed  by  pressure  or  distention.  Cripps  describes 
two  other  cases  of  a  similar  nature.  The  benign  nature  and  extreme 
rarity  of  this  type  of  tumor  render  a  prolonged  discussion  superfluous. 

Dermoid  Cyst. — Here  one  must  clearly  distinguish  between  true 
dermoids  of  the  rectum  and  those  which  develop  in  its  walls,  the  recto- 
vaginal sseptum  or  the  retro-rectal  space.  Such  tumors  are  not  at  all 
infrequent  in  these  regions,  but  true  dermoids  of  the  rectum  are  ex- 
tremely rare. 

Those  which  originate  outside  of  the  rectum  may  break  through  into 
it  by  ulceration  or  rupture,  and  thus  protrude  in  a  polypoid-like  man- 
ner into  the  gut,  giving  the  impression  of  a  growth  originating  within 


Y48  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

the  organ.  Such  a  case  has  been  related  by  Jardine  (Glasgow  Med., 
1893,  p.  50):  A  little  girl  aged  ten  years  suffered  from  a  discharge  of 
blood  and  pus  ^Yith  her  stools,  and  during  defecation  there  protruded 
from  her  anus  a  mass  of  tufted  hair  matted  together.  A  careful  exam- 
ination of  this  child's  rectum  showed  a  rent  in  the  wall  with  ulcerated 
edges,  through  which  the  discharge  came  and  the  tumor  protruded.  It 
was  clearly  a  case  of  a  dermoid  cyst  originating  outside  of  the  rectal 
wall  that  was  forced  through  by  straining  and  abdominal  pressure. 

Port  (Transactions  of  the  Path.  Soc.  of  London,  1880,  p.  307)  relates 
the  case  of  a  girl  aged  sixteen,  from  whom  he  removed  a  tumor  appar- 
ently originating  in  the  rectum.  It  was  composed  of  skin  covered  with 
hair  and  sebaceous  follicles;  its  central  mass  was  chiefly  composed  of 
fat  and  fibrous  tissue,  and  within  the  central  cavity  there  was  found 
a  well-developed  tooth  growing  near  the  pedicle.  There  were  also  em- 
bedded in  this  tumor  two  masses  of  bony  svibstance,  one  hard  and  the 
other  of  a  spongy  consistence.  While  the  patient  is  said  to  have  ex- 
perienced the  protrusion  of  a  tuft  of  hair  frequently  when  at  stool, 
no  account  is  given  of  such  a  tuft  being  found  upon  the  surface  of  the 
tumor  after  it  was  removed. 

Bazel  (Langenbeck's  Archiv,  Bd.  xvii,  S.  442)  related  the  case  of  a 
woman  who  suffered  from  a  protrusion  of  hair  from  the  anus  when 
at  stool.  He  removed  from  her  rectum  a  tumor  the  size  of  an  orange, 
which  was  attached  by  a  pedicle  to  the  posterior  wall  of  the  rectum 
about  2^  inches  above  the  anus.  Upon  an  examination  of  the  tumor 
it  was  found  to  be  composed  of  a  sort  of  dermoid  covering  from  which 
were  seen  growing  long  tufts  of  hair,  and  at  one  place  a  small  tooth. 
Inside  there  was  a  distinct  development  of  brain  substance  surrounded 
by  a  sort  of  bony  capsule,  together  with  fibrous  and  fatty  cells. 

Barker  (Med.  Press  and  Circ,  1873,  p.  208)  described  a  tumor  of 
the  rectum  composed  of  bone,  sebaceous  matter,  and  small  hairs.  This 
was  in  all  probability  a  dermoid  cyst,  but  the  description  is  so  imperfect 
that  one  can  not  tell  whether  it  originated  within  the  rectal  wall  or 
outside  of  it. 

Glutton  (Transactions  of  the  Path.  Soc.  of  London,  1886,  p.  552) 
has  reported  a  case  of  a  girl  nine  years  of  age,  who  suffered  extremely 
with  constipation',  tenesmus,  and  the  presentation  of  a  tumor  at  the  anus 
whenever  the  bowels  moved.  She  also  complained  at  times  of  fever  and 
loss  of  blood.  An  examination  of  the  abdomen  showed  a  distinct  ten- 
derness over  the  sigmoid  flexure,  and  also  the  existence  of  a  tumor  in 
that  region.  After  a  short  time  the  sphincters  were  dilated,  and  the 
tumor  was  seen  to  come  down  well  into  the  rectum  within  reach.  An 
examination  elicited  the  fact  that  this  tumor  was  attached  by  a  double 
pedicle  which  originated  about  the  juncture  of  the  rectum  and  sigmoid 


BENIGN  TUMORS  OP  THE  RECTUM  T49 

flexure.  A  ligature  was  placed  upon  each  of  the  pedicles  as  high  up  as 
the  fingers  could  reach,  and  the  tumor  was  removed.  An  examination 
of  the  growth  showed  it  to  be  a  typical  dermoid  cyst,  covered  with  true 
skin  tissue  and  hairs,  and  containing  all  the  elements  usually  found 
in  these  growths. 

Gant  has  also  reported  a  case  of  this  kind.  ISTo  explanation  has 
yet  been  offered  of  the  method  of  development  of  these  tumors  within 
the  rectum.  While  those  posterior  to  the  rectum  have  been  said  to 
originate  in  the  remnants  of  the  neurenteric  canal,  it  seems  impossible 
for  those  developing  in  the  upper  regions  of  the  rectum  to  have  so 
originated. 

Golding-Bird  (Lancet,  1894,  vol.  ii,  p.  1482)  removed  a  tumor 
from  the  walls  of  the  rectum  by  incising  the  mucous  membrane  over 
the  growth  and  ligating  the  pedicle.  An  examination  of  the  tumor 
showed  it  to  be  cystic,  filled  with  a  clay-like  fluid,  and  containing  all 
the  structural  elements  found  in  the  wall  of  the  large  intestine.  The 
author  considered  it  without  doubt  a  dermoid  cyst  originating  in  the 
walls  of  the  rectum.  Huntt  (Med.  Eepository,  1821,  p.  79)  relates  the 
case  of  a  little  girl,  twelve  years  of  age,  who  had  become  weak,  anasmic, 
and  her  abdomen  swollen  and  tympanitic.  One  day  she  felt  something 
give  way  in  the  left  side,  and  immediately  thereafter  she  passed  a  con- 
siderable quantity  of  bloody  water  by  the  rectum.  This  was  followed 
in  a  few  days  by  a  discharge  of  pus,  blood,  and  mucus.  Some  four 
weeks  later  a  spherical  tumor  presented  itself  at  the  anus,  partially 
protruding.  As  its  presence  caused  the  patient  much  pain  and  an  un- 
controllable desire  to  defecate,  an  immediate  removal  became  necessary. 
A  ligature  was  placed  as  high  up  as  possible,  and  the  greater  part  of  the 
tumor  was  cut  away.  The  rest  of  it  eventually  sloughed  off,  and  the 
child  made  a  good  recovery.  The  growth  v/as  covered  with  hair  and 
a  sort  of  dermal  tissue,  and  in  its  center  there  were  found  two  teeth, 
together  with  flbrous  and  fatty  tissue. 

Van  Duyse  (Bull,  of  Anat.  Eoyal  of  Belgium,  Brussels,  1896,  p.  583) 
has  reported  a  case  of  a  woman  thirty-two  years  of  age  who  passed  spon- 
taneously from  her  rectum  during  labor  a  tumor  which,  on  examination, 
proved  to  be  a  dermoid  cyst  partially  encephaloid,  and  containing  a 
rudimentary  eye.  The  patient  developed  no  unusual  symptoms,  and 
made  a  perfect  recovery.  Ko  examination  was  made  with  regard  to  the 
source  of  the  tumor,  or  whether  it  originated  in  the  rectum  or  within 
the  recto-vaginal  sseptum.  The  description  given  leads  one  to  believe 
that  it  originated  in  the  wall  of  the  gut  or  entirely  outside  of  the 
rectum  proper. 

In  the  summer  of  1899,  Prof.  A.  E.  Eobinson  showed  the  writer  a 
tumor  the  size  of  a  foetal  head  which  had  been  passed  from  the  ree- 


750  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

turn  of  a  patient  during  labor.  The  tumor  had  evidently  been  torn 
from  its  capsule  or  attachment  within  the  pelvis,  had  broken  through 
the  rectal  wall,  and  had  been  forced  out  through  the  anus  in  advance 
of  the  child's  head.  Its  pedicle  was  tied  and  cut  off  by  the  midwife. 
It  proved  to  be  a  dermoid  cvst.  He  was  unable  to  induce  this  woman 
to  enter  the  hospital  and  have  proper  treatment,  notwithstanding  there 
was  a  rupture  in  the  wall  of  the  gut  large  enough  to  introduce  several 
fingers  through  it;  she  entered  another  hospital,  was  treated  for  puer- 
peral peritonitis,  and  recovered. 

From  these  experiences  one  must  admit  that,  while  true  dermoid 
cysts  within  the  rectum  are  exceedingly  rare,  one  not  infrequently  finds 
tumors  of  this  tj^e  in  the  walls  of  the  gut  or  attached  to  their  outer 
surface.  These  walls  may  be  ruptured  by  various  processes,  especially 
during  labor,  and  the  tumor  be  brought  down  within  the  gut  or  de- 
livered through  the  anus. 

The  etiological  factor  in  them  all  is  similar  to  that  of  dermoid  cysts 
elsewhere  in  the  body.  They  are  nearly  always  found  in  the  female  sex. 
It  is  perfectly  clear  that  they  are  congenital  from  the  number  of  cases 
found  in  yoimg  children.  That  they  are  not  discovered  until  later  in 
life  is  due  to  the  fact  that  some  patients  are  not  susceptible  to  reflex 
irritability,  or  the  tumor  remains  of  small  size  and  occasions  no  incon- 
venience until  it  offers  an  obstruction  to  the  foetal  head  or  to  a  large, 
hard  stool. 

Extra-rectal  Dermoids. — Dermoid  cysts  may  occur  just  outside  of 
and  attached  to  the  rectal  wall  either  in  the  perinaeum  or  in  the  retro- 
rectal space.  Calbet  (Thesis,  Paris,  1893)  stated  that  these  tumors  were 
comparatively  frequent.  The  writer  has  removed  from  the  retro-rectal 
space  a  tumor  about  the  size  of  a  pigeon's  egg  which  bulged  out  into  the 
rectum  and  led  him  to  believe  that  it  was  in  the  rectal  wall.  It  was 
removed  through  the  rectum  by  dilating  the  sphincter  and  then  making 
a  longitudinal  incision  through  the  wall  of  the  gut.  The  tumor  was 
found  to  be  situated  in  the  cellular  substance  posterior  to  the  rectum, 
and  attached  to  the  rectal  wall,  but  not  in  it.  It  contained  a  lock  of 
hair,  some  sebaceous  material,  and  a  mass  of  partially  developed  bone. 

In  another  operation  upon  a  similar  tumor  situated  just  beneath  the 
peritoneum  in  the  recto-vaginal  sfeptum,  the  woman  had  complained 
very  much  of  irritation  and  pain  when  fascal  passages  were  hard,  and 
had  a  distinct  h^-pertrophic  proctitis,  which  was  the  cause  of  an  aggra- 
vated pruritus.  An  examination  of  the  rectum  showed  this  little  tumor 
about  the  size  of  a  small  olive  situated  2\  inches  above  the  margin  of 
the  anus.  There  was  also  an  adhesion  of  the  uterus  to  the  rectum,  and 
obstruction  to  the  faecal  passages  had  been  noticed  for  a  long  time. 
The  vaginal  cul-de-sac  was  opened,  the  adhesions  were  broken  through, 


BENIGN  TUMORS  OF  THE  RECTUM  751 

the  uterus  was  lifted  up  with  gauze  packing,  the  peritongeum  was 
stripped  upAvard,  and  the  little  tumor,  which  had  a  distinct  pedicle,  was 
enucleated  and  the  pedicle  twisted  off.  It  was  composed  of  a  dense, 
fibrous  capsule  enclosing  a  soft,  yellowish,  semifluid  substance,  together 
with  three  pieces  of  bone  and  a  partially  developed  eye-tooth. 

Manuel  (Senn  on  Tumors)  refers  to  2  cases  of  dermoid  cysts  which 
were  situated  between  the  peritonseum  and  the  levator  ani  muscle. 

Konig  reported  the  case  of  a  supf)urating  cyst  found  enclosed  in  this 
same  locality.  Ord  (Med.  Chir.  Transactions,  vol.  xlii,  p.  1)  found  in 
the  pelvis  of  a  man  twenty-eight  years  of  age  a  dermoid  cyst  weighing 
141  pounds;  but  he  does  not  state  whether  this  was  within  the  peritoneal 
cavity  or  extra-peritoneal. 

Page  (Brit.  Med.  Jour.,  1890,  vol.  i,  p.  406)  removed  a  dermoid  cyst 
weighing  3  pounds  from  the  hollow  of  the  sacrum  in  a  woman  thirty- 
eight  years  of  age.  These  cysts  may  also  develop  outside  of  the  anus, 
as  in  the  case  of  Duret  related  by  Fourneaus  (Jour,  des  scs.  med.  de  Lille, 
1893,  p.  346).  The  patient  in  this  case  was  thirty  years  of  age,  and  had 
carried  this  cyst  at  the  margin  of  the  anus  supposedly  from  birth.  The 
tumor  was  of  a  dark-red  color,  which  extended  down  even  into  the  ped- 
icle by  which  it  was  attached.  Its  surface  was  richly  vascular,  and  cov- 
ered with  a  thin,  smooth  skin  continuous  with  the  skin  of  the  anus.  The 
tumor  was  removed  by  incising  the  skin  around  the  pedicle,  dragging 
down  upon  the  latter  and  cutting  it  off,  the  edges  of  the  skin  being  su- 
tured together.  Duret  was  under  the  impression  that  this  tumor  was 
a  melicerous  cyst.  Microscopic  examination  showed  that  it  was  one  of 
the  rare  tjrpes  of  dermoids. 

Treatment. — These  tumors  should  be  removed  either  by  ligature  or 
dissection  under  the  most  rigid  antisepsis.  Cauterization,  curettage,  and 
local  treatment  are  worse  than  useless  in  such  cases. 

Postanal  Dimples. — Along  with  dermoid  cysts  one  may  consider 
''  postanal  dimples  "  which,  according  to  histologists,  are  due  to  similar 
imperfections  in  the  development  of  the  embryo.  They  occur  chiefly  in 
the  region  of  the  sacrum,  coccyx,  and  posterior  margin  of  the  anus,  and 
are  said  to  be  caused  by  imperfect  union  between  the  two  lateral  halves 
of  the  foetal  body. 

They  occur  as  slight,  fissure-like  (Fig.  247a),  or  cylindrical  depres- 
sions (Fig.  2475)  in  the  skin,  varying  in  depth  from  several  inches  to  a 
mere  depression  upon  the  surface.  They  are  lined  with  true  epithelium, 
and  contain  sebaceous  glands  and  hair  follicles. 

A  distinction  should  be  made  between  these  and  the  sinuses  which 
occur  in  the  sacro-coccygeal  region  as  a  result  of  obstructed  sebaceous 
follicles.  In  the  latter  hairs  frequently  accumulate,  being  broken  off 
from  the  surface  of  the  body,  and  working  their  way  inward  through 


752 


THE   ANUS,   RECTUM,   AND   PELVIC   COLON 


friction  of  the  clothing;  but  these  can  be  easily  drawn  out,  and  do  not 
show  any  roots.  In  congenital  dimples  the  hairs  grow  down  within  the 
sinus,  and  when  pulled  out  not  only  give  pain,  but  have  distinct  roots 
at  the  end. 

These  little  dimples  from  irritation,  lack  of  cleanliness,  or  other 
causes  may  become  closed  at  the  surface  and  present  the  appearance  of 
small  cysts.  When  pressure  is  exerted  upon  them  under  such  circum- 
stances, sebaceous  material  and  epithelial  debris  may  be  squeezed  out. 


Fig.  :ii7a.— Congenital  Postanal  Fissure.  Fig.  2476. — Congenital  Postanal  Dimi'LE. 

(Markoe  and  Schley,  Am.  Jour.  Med.  Sc,  May,  1902.) 

and  sometimes  even  pus  appears,  produced  by  inflammation  and  infec- 
tion, giving  the  impression  that  one  has  to  deal  with  an  external  blind 
fistula. 

Occasionally  where  suppuration  takes  place  it  may  burrow  downward, 
coming  close  to  the  anus  or  even  entering  the  rectum.  W.  Travis 
Gibb  related  a  case  of  this  kind  in  which  the  fistula  extended  from  the 
middle  of  the  posterior  surface  of  the  coccyx  downward  and  forward, 
ending  near  the  rectum  between  the  external  and  internal  sphincters. 
A  lock  of  hair  extended  almost  through  the  tract.  Wlien  this  was  pulled 
out  the  fistula  appeared  to  be  of  the  ordinary  external  blind  variety,  with 
the  exception  that  the  external  end  was  infolded  and  lined  with  the 
normal  skin.  It  was  laid  open,  curetted,  and  healed,  leaving  a  small 
depression  in  the  skin. 

Treatment. — If  a  dimple  is  deep  and  irritating,  it  may  be  well  to 
dissect  it  out  and  suture  the  edges  of  the  wound  together.  If,  however, 
it  is  simply  a  depression  and  not  irritating,  it  is  better  to  leave  it  alone, 
and  impress  upon  the  patient  the  necessity  of  keeping  the  parts  clean 
without  any  undue  irritation.  Squeezing  and  digging  at  them  is  harm- 
ful, and  should  be  avoided. 

Occasionally  pulling  the  hairs  out  and  cauterizing  the  tract  with 


BENIGN  TUMORS  OP   THE  RECTUM  Y53 

nitrate  of  silver  will  result  in  their  obliteration^  but  if  a  small  piece 
of  adhesive  plaster  is  worn  over  the  opening,  the  dimple  will  be  kept 
clean  and  rarely  give  any  inconvenience. 

Sacro-coccygeal  Tumors. — Certain  sacral  and  sacro-coccygeal  growths 
develop  upon  the  anterior  surface  of  the  sacrum  or  coccyx,  and  may  be 
mistaken  for  tumors  of  the  rectum,  or  may  originate  outside  of  these 
bones  and  extend  inward,  and  thus  seem  to  be  connected  with  the  gut. 

In  discussing  them  it  may  be  well  to  refer  to  Sutton's  theory  of 
embryological  formation  of  tumors  in  this  region.  He  says:  "In  the 
early  embryo  the  central  canal,  spinal  cord,  and  alimentary  canal  are 
continuous  around  the  caudal  extremity  of  the  notochord.  The  passage 
which  unites  them  is  known  as  the  neurenteric  canal.  When  the 
proctodseum  invaginates  to  form  a  part  of  the  cloacal  chamber  it  meets 
the  gut  at  a  point  some  distance  anterior  to  the  spot  where  the  neuren- 
teric canal  opens  into  it.  Hence  there  is  for  the  time  a  segment  of  the 
intestine  extending  behind  the  anus,  and  termed,  in  consequence,  the 
postanal  gut.  Afterward  this  section  disappears,  leaving  merely  a  trace 
of  its  existence  in  a  small  structure  at  the  tip  of  the  coccyx,  known 
as  the  coccygeal  gland  or  gland  of  Luschka." 

The  embryonic  tissue  thus  left  is  a  fertile  source  of  tumors  of  the 
congenital  cystic  variety.  In  this  region,  therefore,  we  may  meet  several 
different  forms:  dermoid  cysts  or  foetal  inclusions;  tumors  of  the  coccyg- 
eal gland  arising  from  the  remains  of  the  postanal  gut;  and  tumors  of 
the  neurenteric  canal. 

Calbet,  Braune,  Molk,  and  Taneffi  have  made  special  studies  of  these 
cases,  and  their  results  are  extremely  interesting.  Calbet  reports  111 
cases  and  Molk  115. 

The  most  common  point  of  origin  is  upon  the  anterior  surface  of  the 
coccyx  and  sacrum.  The  next  most  coramon  point  is  upon  the  posterior 
surface  of  the  sacrum.  The  neoplasms  found  here  are  various,  consisting 
of  mixed  tumors,  lipomata,  sarcomata  in  different  forms,  carcinomata, 
dermoid  cysts,  fibroids,  and  simple  cysts.  The  most  common  type  of  the 
tumors  seems  to  be  a  sarcomatous  degeneration  of  the  fibrous  tissue. 
They  are  largely  found  in  children,  and  are  nearly  all  congenital.  Many 
in  which  the  growths  have  been  found  were  still-born,  and  others  died 
soon  after  birth.  In  Calbet's  statistics  60  per  cent  died  before  the  end 
of  the  second  year. 

In  83  observations  by  this  author  the  tumors  were  composed  of 
foetal  tissue;  there  were  50  deaths  and  23  cures  or  ameliorations.  As 
results  of  operative  treatment,  Molk  collected  31  cases  with  14  recov- 
eries, and  Calbet  53  cases  with  37  recoveries,  a  total  of  84,  with  33  deaths, 
or  a  mortality  of  39.3  per  cent.  From  these  statistics  one  can  not  but 
conclude  that  the  prognosis  of  such  tumors  is  very  grave,  and  much 
48 


754  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

more  so  because  one  includes  among  these  those  distressing  cases  of 
spina  bifida  occurring  in  tlie  anterior  wall  of  the  sacrum,  and  producing 
what  appears  to  be  a  tumor  of  the  rectum. 

While  sarcoma  is  the  ordinary  form  of  malignant  tumors  found  in 
this  location,  it  is  not  the  only  one.  Fletcher  and  "Waring  (Transac- 
tions of  the  Path.  Soc.  of  London,  1900)  relate  the  case  of  a  child  aged 
two  years  who  was  operated  on  for  the  removal  of  a  tumor  in  the  coc- 
cygeal region,  which  had  been  present  from  birth.  It  was  removed  by 
a  perineal  incision.  The  coccyx  was  excised,  owing  to  its  attachment  to 
or  involvement  in  the  tumor,  and  the  patient  made  a  very  good  recov- 
ery. An  examination  of  the  growth  showed  it  to  consist  of  two  parts: 
one  a  dense,  hard,  semisolid  substance  and  the  other  soft  and  com- 
pressible. The  soft  part  proved  to  be  an  adeno-carcinoma,  while  in 
the  dense  part  there  were  numerous  tubules  of  various  sizes  lined  with 
columnar  epithelium,  with  a  considerable  quantity  of  vascular,  connect- 
ive tissue.  Two  and  a  half  months  later  this  patient  returned  to  the 
hospital,  and  died  shortly  afterward.  The  autopsy  revealed  the  fact  that 
the  pelvis  was  filled  with  recurrent  masses  of  adeno-carcinoma.  The 
writers  assume  that  the  origin  of  this  tumor  was  in  the  postanal  gut. 
They  also  report  the  case  of  a  child  who  died  on  the  seventh  day  after 
an  operation  for  an  adeno-cy stoma  originating  in  the  neurenteric  canal. 

Spina  bifida  may  also  occur  in  this  region,  not  only  alone,  but  as 
a  complication  of  other  tumors;  this  is  a  fact  which  is  not  ordinarily 
appreciated.  The  writer  came  very  near  mistaking  such  a  tumor  for 
an  ordinary  cyst  some  years  ago,  and  was  only  deterred  by  the  wisdom 
and  kind  advice  of  L.  Emmett  Holt,  who  had  seen  the  case  before, 
and  warned  him  to  carefully  exclude  anterior  spina  bifida  before  under- 
taking the  operation.  A  very  careful  study  of  the  case  demonstrated 
that  Dr.  Holt  was  right  in  his  diagnosis.  The  proposed  operation  would 
almost  surely  have  proved  fatal. 

Treatment. — The  fact  that  most  of  these  tumors  are  malignant  in 
character  renders  the  prognosis  very  unfavorable.  Excision  offers  the 
only  hope  of  cure,  but  it  should  never  be  undertaken  without  a  perfect 
knowledge  on  the  part  of  the  patient,  or  the  parents,  of  the  probable 
outcome.  The  operation  should  be  done  under  the  strictest  aseptic  pre- 
cautions entirely  outside  of  the  rectum,  even  if  the  coccyx  and  a  part 
of  the  sacrum  have  to  be  removed  to  accomplish  it.  In  anterior  spina 
bifida,  either  simple  or  complicated,  the  prognosis  is  so  grave  that  it 
is  doubtful  whether  any  operative  interference  is  justifiable. 

Angeioma. — This  type  of  tumor,  consisting  of  dilated  venous  capil- 
laries bound  together  with  connective-tissue  bands,  occasionally  occurs 
in  the  rectum,  forming  a  sort  of  nevoid  mass.  It  is  derived  from  the 
submucosa,  and  is  ordinarily  congenital.    Barker  (Med.  and  Chir.  Trans- 


BENIGN  TUMORS  OP   THE  RECTUM  755 

actions,  1883-'8-i,  p.  229)  records  the  case  of  a  man  forty-five  years  of 
age  wlio  died  of  anaemia,  tlie  result  of  severe  rectal  ligemorrhages.  Mi- 
croscopic examination  after  death  showed  that  the  tumor  from  which 
the  bleeding  occurred  was  an  unmistakable  angeioma  or  nsevus. 

Another  case  of  this  kind  is  reported  by  Marsh  (Med.  and  Surg.  Soc, 
1883).  A  little  girl  ten  years  of  age  had  suffered  with  rectal  hsemor- 
rhages  for  eight  years;  an  examination  with  the  speculum  showed  a 
ngevus  entirely  surrounding  the  rectum  and  ascending  1^  inch  above 
the  anus.  In  this  case  the  neoplasm  was  treated  by  the  use  of  Dupuy- 
tren's  cautery,  which  gave  relief  but  did  not  cure  the  condition.  Mar- 
tin, of  Cleveland^  has  also  seen  a  case  of  this  type  in  an  adult. 

In  all  of  these  cases  the  history  of  the  disturbances  dates  back  many 
years,  and  it  is  presumable  that  they  Avere  congenital. 

Treatment. — The  rarity  of  these  cases  renders  it  impossible  to  speak 
from  experience  with  regard  to  their  treatment.  It  seems  reasonable  to 
suppose,  however,  that  the  Wliitehead  operation  would  effectually  re- 
move these  growths  if  low  down  in  the  rectum;  if  high  up,  electrolysis 
would  probably  be  the  safest  procedure. 

Verruca. — These  growths,  known  also  as  warts,  vegetations,  condy- 
lomata and  papillomata,  are  found  frequently  around  the  margin  of  the 
anus,  especially  in  stout  individuals.  So  frequently  are  they  associated 
with  genito-urinary  affections  that  they  are  frequently  called  venereal 
warts.  Aside  from  the  type  known  as  condylomata  lata,  which  is  a 
variety  of  mucous  patch,  the  growths  are  in  no  wise  venereal  in  the 
strict  sense  of  the  word.  They  consist  of  a  simple  hypertrophy  of  the 
papillary  layer  of  the  skin.  This  hypertrophy  may  be  caused  by  any 
chafing  or  irritating  discharge.  It  depends  essentially  upon  moisture, 
and  therefore  the  condition  is  never  observed  in  people  who  are  strictly 
attentive  to  personal  cleanliness. 

The  growths  sometimes  develop  upon  the  summits  of  mixed  haemor- 
rhoids, but  here  they  attain  only  a  small  size.  Around  the  margin  of 
the  anus  they  may  grow  to  enormous  proportions,  entirely  surrounding 
this  organ  and  extending  forward  over  the  perineum,  upon  the  vulva 
or  scrotum,  and  upward  into  the  inguinal  region  (Plate  V,  Fig.  1). 

Careful  research  has  failed  to  determine  any  specific  bacillus  or  para- 
site to  account  for  them.  They  begin  as  small  wart-like  excrescences, 
and  develop  rapidly  in  proportion  to  the  amount  and  irritating  qualities 
of  the  discharges  which  bathe  them. 

The  color  varies  from  pale  white  to  that  of  bright  red,  and  some- 
times the  condition  much  resembles  a  vegetating  epithelioma.  The  dis- 
tinguishing feature  between  these  conditions  is  the  absence  of  any  in- 
duration in  the  deeper  tissues  at  the  bases  of  the  vegetations.  Some 
are  covered  with  a  firm  epithelial  layer,  and  may  be  handled  with  im- 


756  THE   AXUS,   RECTUM,   AND   PELVIC   COLON 

punity  so  far  as  pain  and  bleeding  are  concerned.  In  others,  wi[)ing 
or  cleansing  them  will  result  in  quite  considerable  and  obstinate 
bleeding. 

The  growths  are  not  painful,  as  a  rule,  but  when  they  involve  the 
muco-cutaneous  margin  they  may  result  in  such  dragging  upon  the 
mucous  membrane  as  to  produce  anal  fissure,  and  this  becomes  a  source 
of  great  pain. 

Treatment. — The  treatment  of  these  growths  may  be  operative  or 
non-operative.  Certainly  the  most  radical  and  quick  method  of  eradica- 
tion consists  in  clipping  them  off  at  their  bases  with  scissors,  and  using 
hot  compresses  to  control  the  bleeding.  This  method  is  always  eifectual, 
and  is  without  any  particular  danger  if  thorough  antiseptic  irrigation 
is  employed  during  the  operation.  It  requires  general  anesthesia,  how- 
ever, in  extensive  growths. 

The  non-operative  treatment  consists  in  checking  the  discharges 
from  whatever  sources  they  may  come,  in  keeping  the  parts  absolutely 
dry  by  the  application  of  such  powders  as  oxide  of  zinc,  calamine,  starch, 
tannic  acid,  calomel,  etc.  The  tumors  may  be  cauterized  from  time  to 
time  with  chromic  or  nitric  acid,  or  better  still  with  monochloracetic 
acid.  The  chief  point,  however,  in  the  treatment  consists  in  keeping  the 
parts  absolutely  dry,  and  this  is  essential  after  operation  by  excision, 
as  the  vegetations  will  imdoubtedly  recur  unless  the  parts  are  protected 
from  the  irritating  discharges  which  originally  caused  them. 

Fungus  of  the  Rectum. — Under  the  name  of  "  fungus  recti  "  a  num- 
ber of  distinctly  different  conditions  have  been  described;  some  of  them 
are  merely  inflammatory  excrescences,  some  true  papillomata,  and  others 
S3'philitic  vegetations. 

Molliere  has  described  imder  this  class  of  cases  a  form  which  he  de- 
nominates "  benign  fungus  of  the  rectum."  It  is  in  reality  only  a  mass 
of  granulation  tissue  due  to  constant  irritation.  He  observed  it  always 
in  children  suffering  from  prolapse  or  inflammation  of  the  rectum.  The 
fungus  was  nothing  more  or  less  than  an  hypertrophy  of  the  villi  or 
granulation  tissue  over  the  ulcerated  areas.  Around  the  anus,  however, 
a  true  fungoid  growth  may  be  met  with.  This  consists  in  the  ray  fungus, 
technically  called  actinomycosis.  The  condition  is  extremely  rare.  Do- 
lore  (Lyon  medical,  1898,  July  10)  gives  a  clear  description  of  this  con- 
dition, and  states  that  it  is  the  only  case  reported  in  French  literature: 
A  man  fifty-six  years  of  age  had  suffered  twenty  years  previously  from 
an  ischio-rectal  abscess  which  healed  rapidly.  Marked  induration  was 
observed  in  the  ischio-rectal  fossa,  and  masses  of  fungoid  growth  sur- 
rounded the  anus,  through  which  ran  many  fistulous  tracts.  The  rectum 
was  not  affected,  nor  was  the  bladder  or  urethra,  the  condition  being 
perirectal  and  periurethral.     A  flaky,  yellowish-white  discharge  exuded 


BENIGN  TUMORS   OF  THE  RECTUM  757 

from  the  mass,  and  on  examination  it  was  foimd  to  contain  the  spores 
of  actinomycosis.  The  presence  of  these  peculiar-looking,  yellowish- 
white  granules,  resembling  somewhat  the  crystals  of  iodoform  and 
consisting  of  a  center  of  fine  granular  matter,  generally  calcareous, 
grouped  about  which  were  numerous  club-shaped  bodies  composed  of  a 
limiting  membrane  with  a  clear,  homogeneous,  refractile  protoplasm, 
were  considered  pathognomonic  evidences  of  the  ray  fungus.  It  is 
spoken  of  by  dermatologists  as  the  cause  of  pruritus  ani,  but  it  is  cer- 
tainly a  very  rare  cause  of  this  condition,  as  we  are  unable  to  find  a 
single  case  of  it  recorded  in  the  records  of  St.  Mark's  Hospital,  and  none 
has  appeared  at  our  clinic. 

Hydatids. — This  variety  of  tumors  does  not  occur  within  the  rectum, 
but  a  number  of  cases  have  been  reported  in  which  the  tumors  occurred 
in  Douglas's  cul-de-sac,  in  the  mesorectum,  and  in  the  recto- vaginal  ssep- 
tum,  and  could  be  felt  through  the  rectal  wall.  In  some  instances  this 
wall  has  been  so  thinned  by  the  pressure  of  the  tumors  that  they  have 
ruptured  through  into  the  gut. 

About  4  per  cent  of  these  tumors  occur  in  the  pelvis.  According 
to  Jensen,  Madelung,  Freund,  and  Yillard,  they  are  found  in  women, 
as  a  rule.  An  interesting  case  of  this  type  has  been  recently  reported 
by  Bangs  (Annals  of  Surgery,  May,  1900);  the  tumors  seemed  to  involve 
the  bladder  and  prostate,  but  were  afterward  found  to  be  in  the  recto- 
vesical pouch  and  crowding  the  pelvic  organs;  they  were  removed  by 
an  operation  through  the  abdomen,  and  the  patient  made  a  successful 
recovery. 

Diagnosis. — The  diagnosis  of  these  tumors  is  extremely  difficult. 
There  is  nothing  characteristic  in  their  feel,  shape,  or  sj-mptoms  to 
distinguish  them  from  other  tumors  found  in  the  same  location.  Or- 
dinarily the  diagnosis  is  only  made  after  or  during  an  operation  for  their 
removal.  The  hydatid  thrill  is  said  by  some  to  be  of  assistance  in 
distinguishing  them,  but  when  the  tumor  is  situated  in  the  pelvis  it  is 
impossible  to  make  this  out.  Practically  the  diagnosis  can  only  be  made 
by  the  microscopic  examination  of  the  fluid.  If  the  tumor  is  within 
reach  this  may  be  obtained  through  an  aspirating  needle,  under  strict 
antiseptic  precautions,  the  presence  of  a  single  hydatid  booklet  being 
pathognomonic  evidence  of  the  nature  of  the  growth.  Should  the  cyst 
rupture  into  the  rectum  the  booklet  may  be  found  in  the  fsecal  dejecta. 

While  the  seat  of  these  tumors  is  usually  in  the  peritoneal  cavity, 
between  the  rectum  and  the  uterus,  or  the  rectum  and  bladder  in  males, 
this  is  not  always  the  case.  Meyer,  quoted  by  Piecheldt  (Commentatio 
de  Tumoribus  in  Pelvi,  Heidelberg,  IS-IO),  performed  a  laparotomy  for 
a  tumor  of  the  pelvis  which  he  supposed  to  be  a  steatoma,  but  it  proved 
to  be  a  mass  of  hydatids  between  the  rectum  and  the  upper  vaginal  wall. 


758  THE  AXUS,   RECTUM,   AND   PELVIC  COLON 

Unfortunately  his  patient  died  forty  hours  later  from  peritonitis.  Blot 
(Compte  rend,  de  la  soe.  de  biol.,  1859)  and  Roux  (Jour,  de  med.  de 
Sedillot,  1828)  both  relate  cases  in  which  the  h^'datids  were  found  in 
the  recto-vaginal  sfeptum. 

Obre  (Transactions  of  the  Path.  Soc,  185-i)  reported  a  very  inter- 
esting case  in  which  rectal  obstruction  was  due  to  hydatid  cysts  in  the 
mesorectum.  Madelung  has  collected  66  cases  of  pelvic  hydatids,  5  of 
which-  were  between  the  vagina  and  the  rectum,  and  7  in  the  connective 
tissue  about  the  rectum.  Although  these  cases  are  rare,  they  are  suffi- 
ciently well  authenticated  to  put  us  upon  our  guard  when  diagnosticat- 
ing tumors  of  the  pelvis  involving  the  rectum.  They  are  quite  im- 
portant, because  they  are  more  dangerous  than  almost  any  other  form 
of  cyst  in  this  region. 

Treatment. — The  results  of  operations  have  not  been  very  satisfac- 
tor}'.  The  majority  of  writers  believe,  where  the  diagnosis  is  once  made 
and  the  tumor  does  not  seem  to  cause  much  annoyance  or  to  give  great 
pain,  that  they  had  better  be  left  alone.  If  it  should  be  necessary  to 
interfere  with  them,  however,  a  radical  and  complete  removal  of  the 
cyst  is  the  only  safe  method.  If  possible  they  should  be  removed  un- 
broken. 

The  injection  treatment,  whether  by  iodine,  carbolic  acid,  or  Mor- 
ton's fluid,  and  tapping,  are  not  only  ineffectual,  but  may  cause  actual 
harm  by  allowing  the  fluid  of  the  tumor  to  escape  into  the  cellular 
tissues  or  into  the  peritoneum,  which  accident  is  nearly  always  fol- 
lowed by  a  rapid  fatality. 

Hypertrophied  Anal  Papillae. — In  connection  with  the  benign  neo- 
plasms of  the  rectum  we  may  call  attention  to  certain  h}-pertrophies  of 
the  papilla  about  the  margin  of  the  anus.  They  can  scarcely  be  termed 
neoplasms,  being  only  excessive  growths  of  normal  tissues.  They  con- 
sist in  marked  hypertrophy  of  the  anal  papillae  normally  found  upon  the 
borders  of  the  semilunar  valves;  it  may  take  place  in  one  or  more  of 
them,  and  they  may  attain  considerable  size  and  length  (Fig.  248). 
While  these  growths  are  said  to  be  highly  endowed  with  sensitive  nerve- 
ends,  they  rarely  produce  any  pain.  They  occasion,  however,  a  great 
deal  of  uneasiness  in  the  rectum,  spasm  and  hy]3ertrophy  of  the  sphinc- 
ter, and  consequently  constipation,  associated  sometimes  with  neuralgia 
of  the  rectum.  They  appear  like  little  white  fibrous  teats  or  warts;  they 
can  be  seen  through  the  speculum,  and  sometimes  by  dragging  down  on 
the  buttocks.    They  are  also  appreciable  to  the  touch. 

A  marked  symptom  of  this  condition  is  the  feeling  of  incompleteness 
in  the  faecal  movements;  the  patient  is  never  perfectly  relieved  by  the 
same  nntil,  through  pressure  and  gradual  retraction,  the  papillae  resume 
their  normal  position  and  the  desire  for  further  stool  then  passes  away. 


BENIGN  TUMORS  OF  THE  RECTUM 


759 


The  amount  of  disturbance  and  annoyance  occasioned  by  these  little 
teats  can  hardly  be  appreciated  by  those  who  have  not  observed  them. 
Occasionally  they  grow  to  such  an  extent  that  they  are  mistaken  for 
polypi  of  the  rectum  or  connective-tissue  hgemorrhoids. 

The  treatment  of  this  condition  consists  in  the  absolute  removal  of 
the  papillge.  This  may  be  done  by  scissors  or  crushing  with  the  hsemor- 
rhoidal  clamp.    As  the  bleeding  is  very  slight  there  is  no  necessity  for 


Fig.  248. — Hyperteophied  Anal  Papillae. 


ligature  or  cautery.  If  there  is  much  hypertrophy  of  the  sphincter,  this 
should  be  done  under  general  angesthesia,  and  a  large  Pennington  tube 
should  be  retained  in  the  anus  for  several  days  in  order  to  obtain  com- 
plete relaxation  of  the  muscle;  otherwise  the  papillae  may  be  removed 
by  the  use  of  cocaine  or  eucaine,  and  the  patient  need  not  be  confined 
to  bed.  While  there  is  little  to  be  said  with  regard  to  the  pathology 
and  treatment  of  this  condition,  it  is  one  of  the  most  fertile  sources 
of  rectal  neurosis. 


CHAPTER   XIX 

MALIGNANT  NEOPLASMS— CARCINOMA  AND   SARCOMA 

Ix  our  general  divisions  of  neoplasms  of  the  rectum  they  were 
classified  as  connective-tissue,  epithelial,  muscular,  and  irregular 
growths.  Those  in  which  the  cellular  elements  are  normally  arranged 
and  fully  developed  have  been  described  as  benign  neoplasms,  and 
those  in  which  these  elements  are  irregularly  arranged,  growing  outside 
of  their  normal  sites  and  imperfectly  developed,  as  malignant.  Car- 
cinoma of  the  epithelial  and  sarcoma  of  the  connective-tissue  type  prac- 
tically comprise  all  the  malignant  tumors  of  the  rectum.  That  doubt- 
ful variety  of  epithelial  growths,  villous  tumor,  might  properly  be  classed 
with  the  former  on  account  of  its  extreme  tendency  to  carcinomatous 
transformation,  if  indeed  it  has  not  always  some  epitheliomatous  foci 
in  it;  but  its  exact  status  is  not  definitely  settled,  and  it  has  seemed 
wise  to  follow  in  the  tracks  of  the  large  majority  of  writers  who  consider 
it  benign. 

CARCINOMA 

Vital  statistics  show  an  alarming  increase  in  the  prevalence  of  carci- 
noma throughout  the  civilized  world.  AVilliams  (Liverpool  Chirurg, 
Jour.,  1895,  p.  56)  has  shown  that  the  disease  has  increased  in  Eng- 
land and  Wales  from  1  in  5,646  in  population  in  1840  to  1  in  403  in 
1894.  The  proportion  of  deaths  from  cancer  to  those  from  all  other 
causes  in  1840  was  1  to  139,  and  in  1894  it  had  increased  to  1  in  23. 
In  the  city  of  New  York,  in  1890,  the  death-rate  from  cancer  was 
1  to  1,679  in  population;  in  1900  it  had  increased  to  1  in  1,394  (statistics 
compiled  for  the  author  by  Dr.  Roger  S.  Tracy).  Parke  (The  Practi- 
tioner, 1899,  p.  378),  in  discussing  this  rapid  increase  in  malignant  dis- 
ease in  the  State  of  New  York,  says :  "  If  for  the  next  ten  years  the 
relative  death-rates  are  maintained,  we  shall  find  that  ten  years  from 
now — viz.,  1909 — there  will  be  more  deaths  in  New  York  State  from 
cancer  than  from  consumption,  smallpox,  and  typhoid  fever  combined." 
This  alarming  prophecy  has  practically  come  true  in  the  adjoining  State, 
New  Jersey,  the  authorities  of  which  have  recently  announced  that 
deaths  from  cancer  during  the  year  1900  were  more  than  those  from 
either  tuberculosis  or  typhoid  fever.  Newsholme  (The  Practitioner, 
760 


malictXaxt  neoplasms— caecixoma  and  sarcoma       "til 

1899,  p.  3T0)  attempts  to  prove  that  this  increase  is  more  apparent  than 
real.  He  practically  admits,  hoverer,  that  modem  methods  of  examina- 
tion and  improved  diagnostic  means  will  accotint  for  only  a  very  small 
proportion  of  the  increase.  It  is  an  incontestable  fact  that  the  disease 
is  becoming  more  and  more  prevalent,  and  bears  each  year  a  larger  and 
larger  proportion  to  the  general  mortality. 

Two  other  facts  which  are  equally  as  discouraging  appear  to  be 
clearly  proved  by  the  statistics  upon  this  subject.  First,  the  increase 
is  most  noticeable  in  the  civilized  and  prosperous  districts;  and,  second, 
the  death-rate  in  proportion  to  the  cases  observed  has  sho-mi  no  material 
reduction.  ]\Iodern  science  has  developed  no  immunizing  or  preventive 
means  to  check  the  onward  march  of  this  most  fatal  malady.  State 
and  national  health  boards  have  devised  all  sorts  of  quarantine  and 
other  methods  for  the  control  of  typhoid  fever,  tuberculosis,  and  -other 
contagious  diseases,  but  no  practical  steps  have  been  taken  with  regard 
to  cancer,  if  we  except  the  State  of  Xew  York,  in  which  there  has  been 
recently  established  a  fund  for  the  study  and  development  of  methods 
for  its  cure. 

Seat  of  the  Disease. — Carcinoma  may  develop  in  any  tissue  or  organ 
of  the  body  where  epithelial  cells  are  found.  Certain  locations,  such  as 
the  mamma;,  the  uterus,  and  the  skin,  are  particularly  prone  to  be  at- 
tacked. The  older  statistics  of  AVilliams  (The  Lancet,  London,  1884, 
vol.  i,  p.  9-3-1),  Jessett  (Cancer  of  the  Alimentary'-  Tract,  London,  1886, 
p.  238),  and  Leichtenstem  (Cyclopgedia  of  the  Practice  of  Medicine, 
1877,  vol.  vii,  p.  63-5)  show  that  3  per  cent  of  all  cancers  occur  in  the 
rectum,  and  that  80  per  cent  of  all  those  found  in  the  intestine  are 
located  in  this  organ.  More  recent  statistics,  however,  show  a  some- 
what higher  percentage  of  the  neoplasms  in  the  rectum.  Zemann 
(Bibliothek  d.  medicin.  TVissenschaften,  Bd.  iii,  H.  1  and  2,  S.  49)  found 
in  21,624  autopsies  at  the  A'ienna  General  Hospital  1.T44  cancers.  Of 
these,  912  involved  the  digestive  tract,  9  of  which  were  in  the  small, 
and  156  in  the  large,  intestine.  Of  the  latter,  30  were  in  the  sigmoid 
flexure  and  81  in  the  rectum.  Heimann  found  in  20,0-54  patients  who 
died  of  cancer  in  the  general  hospitals  of  Prussia  that  10,537,  or  over 
50  per  cent,  involved  the  gastro-intestinal  tract.  Of  these,  2,910  were  in 
the  intestine,  1,204  being  confined  to  the  rectum.  Combining  the  figures 
of  Heimann,  Zemann,  Kronlein  (Deutsch.  Zeitsch.  f.  Chir.,  1900,  S.  53), 
and  De  Bovis  (Eerue  de  chirur.,  Paris,  1900,  tome  i,  p.  679),  we  find  that 
in  a  total  of  45,906  cancers,  2,177,  or  4.8  per  cent,  occurred  in  the  rectum. 
If  we  add  to  these  the  cases  occurring  in  the  sigmoid  flexure,  the  per- 
centage is  raised  to  6.2  per  cent.  From  these  figures  one  must  conclude 
that  cancers  of  the  rectum  and  sigmoid  form  a  somewhat  larger  per- 
centage of  the  total  than  is  generally  admitted. 


762  THE   ANUS,   RECTUM,   AND   PELVIC  COLON 

The  site  in  these  organs  at  which  the  disease  occurs  most  frequently 
is  somewhat  difficult  to  determine.  For  the  purpose  of  studying  this 
feature  the  organs  may  be  divided  into  four  portions — the  anal,  the 
infraperitoneal,  the  supraperitoneal,  and  the  sigmoidal.  The  anal  portion 
includes  all  that  part  of  the  rectum  below  the  internal  sphincter;  the 
infraperitoneal  portion  extends  from  the  internal  sphincter  to  the  tip 
of  the  coccyx,  and  is  about  2  inches  in  extent;  the  supraperitoneal  por- 
tion extends  from  the  tip  of  the  coccyx  to  the  recto-sigmoidal  juncture 
opposite  the  third  sacral  vertebra;  and  the  sigmoidal  portion  from  this 
point  to  the  lower  end  of  the  descending  colon. 

In  a  collection  of  1,029  cases  of  cancer  in  these  organs,  the  disease 
was  located  in  the  anus  and  rectum  901  times,  and  in  the  sigmoid 
flexure  128  times.  Of  those  in  the  anus  and  rectum,  the  seat  of  the 
disease  has  been  quite  definitely  stated  in  602  cases.  The  anus  was 
chiefly  involved  in  6.7  per  cent,  the  infraperitoneal  portion  in  26.3  per 
cent,  and  the  supraperitoneal  portion  in  67  per  cent.  In  many  cases, 
however,  two  or  more  portions  of  the  gut  were  involved  in  the  same 
growth.  The  following  table,  compiled  from  32  personal  observations 
(27  carcinomas  and  5  sarcomas)  shows  the  proportionate  frequency  with 
which  different  portions  of  the  organs  are  chiefly  affected: 

Percentage. 


Anal  portion 3  9.4  per  cent. 

Infraperitoneal  portion 6  18 . 7        " 

Supraperitoneal  portion 18  56.2       " 

Sigmoidal  portion 5  15.6        " 

In  all  but  7  cases  the  recto-sigmoidal  juncture  was  involved  to  a 
greater  or  less  degree  in  the  disease. 

These  figures  are  practically  in  accord  with  those  of  Quenu  and 
Hartmann  (op.  cit.,  vol.  ii,  p.  120),  who  insist  upon  the  frequency  with 
which  carcinoma  involves  the  supraperitoneal  portion  of  the  rectum. 
This  fact  is  of  great  importance,  for  it  demonstrates  that  a  very  large 
proportion  of  cancers  of  the  rectum  can  not  be  extirpated  without  open- 
ing the  peritoneal  cavity,  and  that,  while  many  involve  the  lower  por- 
tion of  the  organ,  very  few  of  them  are  confined  to  it. 

The  types  of  neoplasms  found  in  these  various  sites  may  be  stated 
in  a  general  way  as  follows:  The  squamous  or  pavement  epithelioma  is 
found  in  the  anal  portion;  adeno-carcinoma  and  medullary  cancer  are 
found  in  the  infraperitoneal  and  in  the  lower  portion  of  the  supraperi- 
toneal areas;  medullary  and  scirrhus  carcinomas  are  chiefiy  found  in 
the  supraperitoneal  portion  and  in  the  sigmoid  flexure.  These  rules  are 
not  absolute,  however,  as  we  may  occasionally  find  cylindrical  epithelioma 
or  medullary  cancer  in  the  anus,  and,  as  Quenu  and  Hartmann  state. 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA        763 

squamous  epithelioma  may  be  found  high  up  in  the  rectum  following 
prolonged  chronic  proctitis. 

Etiology. — The  cause  of  cancer  is  one  of  the  most  mooted  questions 
in  all  surgical  pathology.  After  centuries  of  discussion  it  is  yet  unsolved. 
Age,  heredity,  occupation,  climate,  locality,  diet,  mechanical  and  chem- 
ical irritants,  animal  and  vegetable  parasites,  have  all  been  accused  of 
producing  the  disease,  and  yet  pathologists  have  not  been  able  to  settle 
upon  any  of  them  as  the  exciting  factor.  Certain  of  them  seem  to  have 
a  predisposing  influence,  but  no  one  can  positively  be  shown  to  produce 
the  disease. 

Eecent  statistics  seem  to  show  substantial  ground  for  belief  in  the 
parasitic  origin  of  the  disease,  and  yet  many  of  the  most  careful  and 
logical  observers  hold  that  the  observations  upon  which  this  theory  is 
based  are  open  to  so  much  criticism  that  nothing  has  yet  been  proved. 

Heredity.— The  influence  of  heredity  in  the  production  of  cancer  is 
firmly  grounded  in  the  popular  mind.  The  fact  that  the  disease  occurs  in 
the  same  family  more  or  less  frequently  lends  color  to  this  belief.  In 
comparison  with  the  number  of  cases  observed,  the  instances  of  hered- 
itary taint  are  very  few;  especially  is  this  true  if  the  comparison  is 
confined  to  the  direct  relationship  between  parent  and  child.  Yery 
often  the  evidence  of  heredity  is  based  upon  the  fact  that  some  distant 
relative,  such  as  an  aunt  or  a  cousin,  third  or  fourth  removed,  has  at 
some  time  in  the  past  suffered  from  this  disease.  The  fact  that  the 
malady  is  one  of  middle  or  later  life  would  contraindicate  the  hered- 
itary influence,  for  it  seems  impossible  that  an  inherited  taint  should 
lie  dormant  for  forty,  fifty,  or  sixty  years  and  then  suddenly  become 
active  at  a  time  when  all  the  vital  processes  are  in  a  state  of  decline. 

In  recent  years  a  number  of  cancers  have  been  seen  in  comparatively 
young  people,  and  among  these  heredity  seems  to  be  somewhat  more 
clearly  established.  In  5  cases  observed  by  the  author  under  twenty-five 
years  of  age,  4  of  them  gave  a  very  clear  history  of  direct  heredity  in  the 
fact  that  one  of  the  parents  in  3  cases  had  died  from  cancer,  and  in 
the  fourth  a  grandmother  and  brother  had  both  died  from  the  same 
disease.  In  the  fifth  case  the  patient  lost  his  parents  very  early  in  life, 
and  could  therefore  give  no  information  as  to  the  cause  of  their  death 
or  his  own  hereditary  tendencies.  Quenu  and  Hartmann  have  observed 
this  same  fact  with  regard  to  young  people.  Stierlin  established  hered- 
ity in  12.5  per  cent  of  his  own  cases,  and  Heuck  in  4.6  per  cent.  Eecog- 
nizing  the  fact,  however,  that  cancer  is  particularly  prone  to  develop 
in  certain  regions,  and  that  generation  after  generation  of  the  same  fam- 
ily are  born  and  reared  in  these  districts,  it  is  more  rational  to  assume 
that  the  cancer  is  due  to  some  local  influence  connected  with  the  soil 
or  water  than  to  heredity. 


764 


THE  ANUS,  RECTUM,   AND  PELVIC  COLON 


Age. — Age  has  always  been  considered  a  predisposing  cause  to  cancer. 
Its  maximum  frequency  is  between  forty  and  forty-five  years  in  all  sta- 
tistics, but  it  is  found  at  almost  every  age.  The  following  table,  com- 
piled from  three  sources,  exhibits  this  fact  remarkably  well: 


Finet's  collection. 

Quenu  and  Hartmann's 
personal  cases. 

Author's  collection. 

Under  20 

I    25 

H 

7 

From  20  to  25 

6 

From  25  to  30 

7 

From  30  to  35 

18 

0 

25 

From  35  to  40 

38 

3 

26 

From  40  to  45 

35 

5 

25 

From  45  to  50 

51 

8 

27 

From  50  to  55 

47 

8 

29 

From  55  to  60 

55 

4 

30 

From  60  to  65 

27 

'    5    < 

24 

From  65  to  70 

20 

f    ''    1 

6 

From  70  to  80 

5 

4 

2 

The  decreasing  frequency  of  the  disease  after  sixty  years  of  age  may 
be  attributed  to  the  comparatively  small  number  of  people  living  at 
this  age. 

With  the  increase  of  cancer,  however,  it  is  observed  more  and  more 
in  young  people.  In  the  vital  statistics  of  New  York  city  for  the  year 
1900  there  were  reported  6  cancers  in  patients  between  five  and  ten 
years  of  age,  4  in  those  between  ten  and  fifteen,  6  in  those  between  fif- 
teen and  twenty,  and  30  in  those  between  twenty  and  twenty-five.  The 
author  has  observed  within  the  past  two  years  7  cases  of  carcinoma 
of  the  rectum  and  3  of  the  sigmoid  fiexure  in  patients  under  thirty 
years  of  age.  Schoening  (Deutsche  Zeitschr.  f.  Chirur.,  1885,  Bd.  xxii, 
and  Annals  of  Surgery,  1885,  vol.  ii,  p.  343)  has  collected  13  cases 
of  cancer  in  individuals  under  twenty  years  of  age.  Allingham  and 
Czerny  have  each  reported  cases  in  children  of  thirteen  years.  May 
has  reported  1  in  a  child  of  twelve  and  Godin  1  in  a  child  of  fifteen. 

In  the  cases  observed  in  children,  it  has  appeared  to  be  not  so  much 
a  question  of  age  in  years  as  age  in  tissues.  Where  there  is  a  tendency 
to  early  retrograde  processes  in  the  animal  economy,  where  the  patient 
matures  prematurely,  carcinoma  is  likely  to  develop  early  in  life.  In 
all  the  cases  in  which  the  disease  has  been  observed  by  the  author  below 
thirty  years  of  age,  there  have  been  evidences  of  premature  decay  in  the 
patient,  such  as  gray  hair,  parched  and  wrinkled  skin,  loss  of  suppleness 
in  the  joints,  and  obstinate  constipation  with  dry,  hard  stools.  It  is  a 
question,  therefore,  whether  the  modern  stress  of  life  may  not  tend  to 
an  earlier  retrograde  movement  in  the  tissues  and  consequent  develop- 
ment of  carcinoma.  Certainly,  the  proportion  of  cancers  occurring  be- 
low the  age  of  thirty-five  years  has  greatly  increased,  and  this  seems 
to  be  the  only  rational  explanation  of  it. 


MALIGNANT   NEOPLASMS— CARCINOMA   AND   SARCOMA         765 

Sex. — While  cancer  in  general  is  incontestably  more  frequent  in 
women  than  in  men,  that  in  the  rectum  is  undoubtedly  more  frequent  in 
men.  Kronlein,  Brandt,  Stierlin,  and  Quenu  and  Hartmann  found  that 
66  per  cent  of  cancers  of  the  rectum  occur  in  males.  In  Finet's  statistics 
63  per  cent  were  found  in  males.  Williams  found  the  disease  in  130 
males  and  129  females,  but  his  experience  is  exceptional.  In  the  cases 
collected  by  the  author,  60  per  cent  were  in  males.  This  does  not  include 
cancers  of  the  sigmoid  flexure,  of  which  80  per  cent  were  found  in  men. 
iSTo  satisfactory  explanation  is  given  of  this  fact.  Those  who  believe  in 
mechanical  and  chemical  irritants  as  the  exciting  cause  of  carcinoma 
attribute  the  frequency  of  the  disease  in  the  generative  organs  of  women 
to  the  frequent  traumatism  to  which  these  parts  are  subjected.  This 
same  school  claims  that  the  preponderance  of  carcinoma  of  the  intestines 
in  men  is  due  to  coarser  diet,  more  rigorous  life,  dissipation,  and  con- 
stant traumatism  to  which  the  intestines  are  subjected  by  straining  at 
heavy  labor  and  athletic  exercises. 

The  influence  of  constipation  and  the  resting  of  the  faecal  mass  at 
certain  portions  of  the  intestinal  canal  would  seem  to  have  some  influ- 
ence in  the  production  of  the  disease,  inasmuch  as  those  portions  of  the 
gut  at  which  the  mass  is  arrested  are  by  far  the  most  frequently  affected. 
This  theory,  however,  meets  an  offset  in  the  fact  that  women  are  pro- 
verbially more  constipated  than  men,  and  therefore  we  would  expect 
to  find  cancers  of  the  intestines  more  frequently  in  this  sex,  whereas 
the  opposite  is  actually  foim^d. 

The  parasitic  theory  of  disease  offers  a  more  acceptable  explanation 
of  these  figures.  Men  travel  very  much  more  widely  than  women.  They 
are  subject  to  the  influence  of  changing  climate,  soil,  and  waters,  and 
are  therefore  more  frequently  exposed  to  whatever  infectious  or  con- 
tagious elements  these  may  possess.  If  this  theor\-  as  to  the  etiolog}'  of 
cancer  is  proved,  it  will  easily  explain  the  preponderance  of  intestinal 
cancer  in  the  male  sex;  at  the  same  time  it  will  cast  just  as  much  doubt 
upon  the  cause  of  its  frequency  in  the  generative  organs  of  women. 
The  fact  that  men  suffer  more  frequently  than  women  from  cancer  of 
the  rectum  is  established,  but  why  we  do  not  know. 

Occupation. — Vocation  is  frequently  spoken  of  as  a  predisposing 
cause  to  cancer,  chunney-sweeps  being  cited  as  marked  illustrations  of 
the  fact.  Experience  and  the  studies  of  Xewsholme  (The  Practitioner, 
1899,  p.  370)  convince  us  that  occupation  has,  if  any,  a  very  slight  eti- 
ological influence  in  the  disease. 

Previous  Diseases. — The  influence  of  previous  diseases  of  the  intes- 
tinal canal  in  the  production  of  carcinoma  seems  to  be  well  established. 
Volkmann,  Quenu  and  Hartmann,  and  Stierlin  claim  that  15  per  cent 
of  all  carcinomas  of  the  rectum  are  preceded  by  heemorrhoids.     These 


766  THE   ANUS,  RECTUM,  AND  PELVIC  COLON 

figures,  however,  are  not  convincing,  for  it  is  an  established  fact  that 
15  per  cent  of  the  individuals  suffering  from  any  class  of  diseases  known 
to  human  nature  are  affected  with  piles.  Dysentery,  colitis,  and  ulcer- 
ative diseases  of  the  intestinal  canal  have  been  frequently  known  to 
precede  the  development  of  cancer.  Prolonged  irritation  of  the  epi- 
thelial tissue  in  these  organs,  as  in  the  lip  or  throat,  will  no  doubt  con- 
tribute to  the  development  of  the  disease,  and  this  may  be  induced  by 
constipation  of  long  standing  or  the  lodgment  of  a  foreign  body  at  some 
portion  of  the  canal.  "While  it  is  stated  farther  on  that  constipation 
is  one  of  the  first  symptoms  of  cancer,  may  it  not  be  that  cancer  is  the 
last  symptom  or  result  of  constipation?  Multiple  polypi,  adenoids,  and 
villous  tumors  frequently  precede  the  development  of  cancer,  and  in 
one  instance  the  author  has  seen  the  neoplasm  develop  in  a  syphilitic 
rectum.  Mucous  or  membranous  colitis  is  frequently  a  precursor  of 
rectal  cancer,  and  thus  derives  a  greater  importance. 

Histological  Types. — There  are  four  elementary  types  of  cancer 
found  in  the  anus,  rectum,  and  sigmoid,  viz.,  epithelioraatous,  ade- 
noid, medullary,  and  scirrhous  carcinomas.  All  of  these  are  subject 
to  colloid,  myxomatous,  mucous,  cystic,  and  ulcerative  changes  which 
alter  their  clinical,  macroscopic,  and  histological  features  to  such  an 
extent  that  the  modified  neoplasms  are  often  described  as  distinct 
types.  These  subdivisions  only  serve  to  confuse  the  reader,  and  the 
author  will  confine  his  descriptions  to  the  simple  types  enumerated 
above. 

From  the  point  of  view  of  malignancy,  cancers  found  in  these  parts 
may  be  mentioned  in  the  following  order:  medullary,  adenoid,  epitheli- 
omatous,  and  least  of  all  scirrhus. 

Carcinomas  are  all  composed  of  two  essential  elements,  the  epithelial 
cells  and  the  stroma,  the  latter  forming  series  of  alveoli  in  which  the 
former  rest.  The  different  varieties  are  distinguished  by  the  character 
of  the  cells  and  amount  of  stroma.  The  epithelial  cells  are  of  the  embry- 
onic type,  and  of  every  shape  and  form — squamous,  cylindrical,  oval, 
caudate,  round,  etc.  They  contain  single  or  multiple  nuclei,  with  prom- 
inent nucleoli.  The  character  of  the  epithelium  is  usually  that  found 
in  the  tissue  in  which  the  carcinoma  develops;  the  shape  of  the  individual 
cell,  however,  is  governed  largely  b}'  the  pressure  to  which  it  is  exposed 
in  the  alveolus. 

Cancer  begins  by  the  epithelial  cells  invading  the  lymphatic  spaces, 
which  they  distend  so  as  to  form  alveoli,  but  do  not  attach  themselves 
to  the  fibrous  walls.  The  stroma  is  composed  of  the  fibrous  or  myxoma- 
tous tissue  of  these  spaces  containing  more  or  less  of  the  histological 
elements  of  the  parts  in  which  the  growth  is  found.  In  the  rectum  it 
frequently  contains  tubules,  follicles,  and  unstriped  muscular  fibers;  it 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA         76Y 


reaches  its  highest  development  in  slowly  growing  tumors,  such  as  scir- 
rhus,  and  its  lowest  in  the  fulminating  variety  of  neoplasms,  such  as 
medullary  cancer.  The  alveoli,  which  connect  with  each  other,  are  the 
original  lymph  spaces  of  the  tissue,  and  are  therefore  freely  connected 
with  the  lymphatics  of  the  parts.  This  fact  accounts  for  the  spread  of 
the  disease  along  the  lymph  channels.  The  blood-vessels  and  nerves 
ramify  in  the  stroma,  but  they  do  not  enter  the  alveoli,  hence  the  dis- 
ease seldom  follows  these  tracts. 

Epithelioma  (Squamous  Epithelioma,  SJcin  Cancer). — The  term  epi- 
thelioma is  often  applied  to  all  types  of  cancer.  In  this  work,  however, 
it  will  be  limited  to 
the  squamous  variety, 
which  occurs  chiefly 
at  the  muco-cuta- 
neous  margin  of  the 
anus.  Histologically 
the  growth  is  charac- 
terized by  the  pres- 
ence of  cuboidal  or 
flat  epithelial  cells  ar- 
ranged in  concentric 
layers.  A  transverse 
section  of  these 
masses  exhibits  the 
so-called  epithelial 
pegs  or  nests  (Fig. 
249).  When  the  cen- 
tral portion  of  the 
epithelia  undergo  fat- 
ty degeneration 
(Heitzmann)  or  hard- 
ening (Coplin),  small, 
shining,  irregular 
masses  are  produced 
known  as  the  cancer 
pearls.  These  pearls 
are  also  seen  in  other 
pathological  condi- 
tions, and  are  not 
therefore  pathogno- 
monic. The  epithelial  cells  invade  the  lymph  spaces  from  the  surface. 
The  stroma  is  comparatively  slight,  and  is  composed  of  connective  tissue, 
partly  fibrous  and  partly  myxomatous,  in  the  specimen  shown.    It  con- 


FiG.  249. — Epithelioma.     (Magnified  200  diameters.) 
iV,  epithelial  nest  with  concentric  arrangement  of  epithelia ;  E, 
epithelial  peg ;  P,  cancer  pearl ;  (7,  connective  tissue  with 
inflammatory  corpuscles  ;  B,  blood-vessel. 


768 


THE   ANUS,   RECTUM,   AND   PELVIC   COLON 


tains  a  moderate  number  of  blood-vessels,  and  is  infiltrated  with  inflam- 
matory corpuscles. 

As  clinically  observed,  epitheliomas  are  largely  confined  to  the  anal 
margin.  They  begin  as  slight  nodular  elevations  in  the  skin  or  Just 
beneath  the  epithelium,  over  which  the  skin  is  not  movable.  When  fully 
developed  they  appear  as  irregular  w^art-like  elevations  wath  indurated 
bases.  The  ulcers  may  discharge  a  watery  or  ichorous  fluid;  they  have  a 
distinct  tendency  to  scab  over,  and  each  time  the  scab  drops  off  the  ulcer 

increases  in  circum- 
ference. Around  the 
edges  of  the  ulceration 
distinct  nodules  are 
observed.  The  course 
of  the  neoplasms  is  to 
surround  the  anus  and 
extend  into  the  skin 
of  the  perinfeum  and 
sacrum  rather  than  up 
into  the  rectum.  The 
tissues  around  the  ul- 
cers are  always  indu- 
rated, but,  as  Coplin 
says,  "  this  induration 
does  not  limit  the  ex- 
tent of  the  tumor." 
The  growth  and  ex- 
tension of  these  neo- 
plasms is  very  slow. 
Squamous  epithelio- 
mas are  sometimes 
very  painful,  at  others 
not  at  all  so;  they  oc- 
casionally bleed  slight- 
ly from  traumatism  or 
abrasion,  but  rarely  if 
ever  occasion  severe 
hemorrhages;  they  are 
distinguished  from  ro- 
dent ulcers  by  the  nodular,  elevated  base  and  excessive  granulations 
(Plate  VI,  Fig.  2). 

Adenoid  Cancer  {Cylindrical  or  Columnar  Epithelioma:  Malignant 
Adenoma). — This  is  the  most  frequent  variety  of  cancer  in  the  rectum 
proper.     It  consists  of  tubular  cavities  of  irregular  form  arranged  in 


Fig. 


250. — ADfcNDJL)  Cancer 


(Magnified  300  diameters.) 
E  E,  convoluted  epithelial  tracts  enclosing  calibers  of  varying 
diameters ;  CC,  connective  tissue  crowded  with  inflamma- 
tory corpuscles ;  B  B,  blood-vessels. 


MALIGIfANT  NEOPLASMS— CARCINOMA   AND   SARCOMA         769 


UJ 


a 


WiA 


-.V 


-B 


r'/X'E^, 


manifold  convolutions,  and  lined  by  cylindrical  or  columnar  epithelium. 
The  tubules  are  separated  by  a  fibrous  or  myxomatous  stroma;  the  convo- 
lutions are  arranged  in  groups;  the  epithelia  are  similar  to  those  lining 
the  Lieberkiihn  follicles 
arranged  at  right  angles 
to  the  stroma  and  possess 
no  basement  membrane; 
they  are  short,  nucleated, 
and  in  many  places 
broken  up  into  medul- 
lary corpuscles  which 
partly  or  completely  fill 
the  caliber  of  the  tubules 
(Fig.  250).  The  stroma 
is  infiltrated  with  these 
corpuscles,  and  contains 
comparatively  few  blood- 
vessels. The  more  rapid 
the  growth,  the  more 
atypical  is  the  glandular 
formation  and  the  small- 
er are  the  cells  and  lu- 
mina. 

Clinically  these 
growths  appear  as  soft, 
sometimes  gelatinous, 
elevated,  lobular  masses. 
Upon  squeezing  or  sec- 
tion they  exude  a  watery 
secretion — the  so-called 
cancer  juice  —  which, 
dropped  into  water, 
turns  milky  white.  They  may  grow  very  rapidly  and  protrude  into  the 
rectum  to  such  an  extent  as  to  obstruct  its  caliber;  they  are  associated 
with  abundant  discharge  of  mucus,  and  often  bleed  very  freely. 

Early  metastasis  is  the  rule,  especially  in  the  liver,  and  the  secondary 
nodules  possess  the  characteristics  of  the  primary  growths.  They  are 
distinguished  from  simple  adenoma  by  the  irregular  arrangement  of  the 
cylindrical  cells  and  the  absence  of  a  basement  membrane,  but  the  fact 
that  simple  adenoma  may  undergo  transformation  into  adenoid  cancer, 
renders  it  very  difficult  to  make  a  diagnosis  between  them.  Certain 
tumors  on  the  border-land  between  the  two  often  exhibit  the  char- 
acteristics of  benign  adenoma  in  one  portion  and  indubitable  carcinoma 
49 


.V 


'^ 


y-/ 


Fig.  251. — Medvllaey  Caxcer.     (Magnified  400 
diameters. ) 
NN^  nests  of  cancer  epitlielia ;  (?,  remnant  of  gland ;  T, 
connective  tissue  crowded  with  inflammatory  corpus- 
cles; 5.  blood-vessel. 


Y70 


THE  AXUS,   RECTUM,   AND  PELVIC  COLON 


in  another.  Small  sections  of  such  growths  are  therefore  unreliable  in 
the  making  of  positive  diagnoses.  On  this  account  it  is  always  best  to 
treat  them  as  if  they  were  well-developed  carcinomas. 

Medullary  Cancer  {Soft  Cancer,  Encephaloid  Carcinoma). — This  is 
the  most  malignant  of  all  types  of  rectal  carcinoma.  It  consists  in  a 
soft,  piilp-like  growth  characterized  by  large  and  irregular  epithelia, 
coarsely  granular  and  multinucleated,  with  scanty  stroma,  fibrous  in  its 
character  and  densely  infiltrated  wath  inflammatory  corpuscles.  The 
epithelia  are  arranged  in  an  irregular  manner,  sometimes  in  nests  (Fig. 
251);  the  alveoli  are  large;  the  stroma  is  often  embryonic  or  myxomatous 
in  character,  and  is  abundantly  supplied  with  blood-vessels.    Clinically 

the  growth  occurs  in  the 
rectum  as  a  soft,  nodular 
ulcerating  mass,  seated  up- 
on or  surrounded  by  dense 
fibrous  tissue.  It  bleeds 
easily  upon  touch,  discharg- 
es abundant  pus,  grows  rap- 
idly, and  soon  involves  the 
neighboring  organs.  It  or- 
dinarily occurs  earlier  in 
life  than  scirrhus,  but  it 
may  result  from  degenera- 
tion of  the  latter.  Glandu- 
lar involvement  is  earlier 
than  in  any  other  form  of 
cancer,  although  remote 
metastatic  deposits  are  not 
so  frequent  as  in  adenoid 
cancer  owing  to  the  fact 
that  it  usually  kills  before 
these  take  place. 

Scirrhous    Cancer    {Fi- 
hrous      Carcinoma,      Hard 
Cancer,  Acinous  Cancer). — 
This  type  of  carcinoma  is 
the     least     frequent     and 
slowest  growing  of  all  can- 
cers of  the  rectum.     It  is 
composed  of  dense  fibrous 
stroma  and  epithelial  cells.    The  stroma  is  so  arranged  as  to  form  a  series 
of  alveoli  which  contain  the  epithelial  cells  (Fig.  252).    The  alveoli  are 
small,  and  the  epithelial  cells  are  atrophied,  compressed,  or  degenerated. 


h 

y ' 


(Magnified  350 


Fig.  252. — Scierhus  of  Intestine. 
diameters.) 
C  T,  dense,  fibrous  connective  tissue ;  A.  alveoli  filled 
with  cancer  epithelia ;  C,  cluster  of  connective-tis- 
sue corpuscles;   E,  row  of  cancer  epithelia;  B, 
blood-vessels. 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA 


m 


There  are  few  blood-vessels  in  the  denser  portions  of  the  tissue, 
but  more  in  the  periphery,  the  walls  of  which  are  thickened  and 
more  or  less  fibrous.  On 
being  cut,  the  tumor  pre- 
sents to  the  naked  eye  the 
appearance  of  a  bluish- 
white  gristly  mass,  con- 
taining here  and  there 
patches  of  fatty  tissue, 
which  are  more  numerous 
near  the  center  of  the  tu- 
mor. If  the  cut  is  made 
through  the  center  of  the 
growth,  the  central  part  of 
the  cut  surface  will  re- 
tract, causing  a  cup-like 
depression,  constituting  the 
so-called  cancer  cup. 

Clinically  these  tumors 
appear  in  the  shape  of  a 
gradually  contracting  stric- 
ture of  the  organ.  They 
cause  no  pain,  very  little 
discharge,  and  no  haemor- 
rhages from  the  rectum. 
Gradually  increasing  and 
intractable  constipation  is 
the  salient  feature.  Ca- 
chexia and  sepsis  are  prac- 
tically absent,  and  unless 
the  tumor  is  transformed 
into  some  other  type,  the 
final  end  occurs  through  intestinal  obstruction  or  rupture  of  the  gut 
above  the  growth. 

Scirrhus  is  subject  to  hyaline,  mucoid,  colloid,  and  fatty  degenera- 
tions. The  chief  change  to  which  it  is  prone  is  transformation  into 
medullary  carcinoma.  Melanosis  has  been  observed,  and  calcareous  in- 
filtration of  the  tumor  is  not  infrequently  seen.  Coplin  has  described  a 
type  of  atrophic  scirrhus  in  which  the  fibrous  tissue  predominates,  and 
the  epithelial  cells  are  therefore  pressed  upon  and  often  disappear  from 
many  areas  of  the  growth.  Under  such  circumstances  the  tumor  grows 
smaller  instead  of  larger.  These  growths,  however,  have  not  been  ob- 
served in  the  rectum. 


Fig.  253. — Colloid  Cancek  of  Large  Intestine. 
(Magnified  350  diameters.) 

F,  connective-tissue  framework ;  E,  cancer  epithelia 
partly  filling  alveolus ;  C,  alveolus  filled  with  col- 
loid substance,  a  number  of  epithelia  unchanged : 
C  T,  connective  tissue  with  medullary  corpuscles  ; 
M,  medullary  corpuscles  ;  M',  medullary  corpuscles 
changing  to  colloid  substance. 


772  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

Colloid  carcinoma  may  develop  from  any  of  the  four  types  which  we 
have  above  described.  It  consists  in  a  degenerative  change  in  the  epi- 
thelial cells  and  in  the  stroma  (Fig.  253).  WTien  the  substance  that  dis- 
tends the  alveoli  is  more  viscid  than  gelatinous,  it  is  called  mucoid  de- 
generation. It  is  said  that  the  colloid  change  occurs  in  the  cell  itself, 
the  mucoid  in  the  intercellular  substance.  Chemically  these  two  condi- 
tions may  be  distinguished,  but  clinically  they  can  not.  As  Coplin 
says:  "  Until  our  methods  of  differentiation  become  more  accurate  and 
we  know  more  of  the  evolution  of  mucoid  and  colloid  carcinoma,  it 
would  probably  be  best  to  consider  them  both  under  the  head  of  gel- 
atinous or  gelatiniform  types  of  cancer." 

Symptoms. — The  spiiptoms  of  cancer  in  these  organs  depend  upon 
the  stage  of  the  disease,  the  type  of  neoplasm,  and  its  site  in  the  canal. 
In  all  carcinomas  which  do  not  result  from  the  transformation  of  other 
tumors  or  pathological  conditions,  there  is  a  latent  period  in  which  no 
symptoms  appear  that  can  not  be  accounted  for  by  other  causes.  The 
local  and  constitutional  manifestations  at  this  period  do  not  in  any 
wise  indicate  the  serious  nature  of  the  disease.  The  existence  of  cancer 
is  therefore  compatible  with  a  perfect  state  of  health  for  considerable 
periods  of  time.  Frequently  patients  with  well-developed  carcinomas 
of  the  rectum  or  sigmoid  recall  that  for  long  periods  they  have  noticed 
vague,  indefinite  discomforts  in  the  regions  of  the  sacrum  or  around  the 
pelvis,  with  increasing  constipation  or  a  tendency  to  diarrhoea  and  some 
slight  derangements  of  the  digestion,  none  of  which  were  severe  enough 
to  attract  any  particular  attention.  Gradual  loss  of  strength,  increased 
pain,  or  unusual  bleeding  from  the  rectum  induces  them  to  consult  a 
surgeon.  Ordinarily  the  disease  is  well  developed  before  this,  and  it  is 
absolutel}^  impossible  to  state  just  when  or  how  it  began. 

The  fact  that  the  first  manifestations  of  carcinoma  may  be  a  vague 
discomfort  in  the  pelvis,  symptoms  of  intestinal  or  gastric  indigestion, 
constipation,  or  a  colicky  tenesmus,  with  or  without  the  passage  of  mucus 
and  flecks  of  blood,  emphasizes  the  importance  of  early  local  examina- 
tions in  patients  with  such  symptoms.  It  is  not  sufficient  to  introduce 
the  finger  3  or  4  inches  into  the  rectum  and,  if  no  neoplasm  or  patholog- 
ical condition  is  observed,  exonerate  the  rectum  and  the  sigmoid  from 
any  part  in  the  production  of  these  symptoms.  A  more  careful  and 
extensive  examination  is  necessary.  By  the  pneumatic  proctoscope 
and  specimen  forceps  (Fig.  254)  it  is  possible  to  bring  into  view 
and  take  sections  from  every  portion  of  the  sigmoid  flexure  and  de- 
termine almost  in  the  earliest  stages  of  this  disease  its  existence  and 
its  site.  The  author  has  by  this  means  diagnosticated  and  afterward 
removed  5  carcinomas  of  the  sigmoid  flexure  in  which  frequent  digital 
examinations  and  abdominal  palpation  had  failed  to  determine  any  path- 


MALIGNANT  NEOPLASMS-CARCINOMA  AND   SAECOMA        YY3 

ological  condition  to  account  for  the  diarrhoea  and  constipation.  In  the 
early  stage,  where  the  carcinoma  is  within  reach,  it  may  appear  as  a 
small  plaque-like  deposit  beneath  the  mucous  membrane  of  the  rectum, 
slightly  movable  upon  the  muscular  wall,  and  decreasing  the  suppleness 
of  the  tissues.  These  deposits  are  chiefly  found  in  the  anterior  and  pos- 
terior segments  of  the  circumference,  although  they  are  occasionally 
seen  in  the  lateral  segments.    They  involve  only  a  small  portion  of  the 


Fig.  254. — Eectai,  SpEcniEN  Fobceps. 


circumference,  and  have  a  tendency  to  extend  in  all  directions.  Such 
deposits  generally  indicate  the  development  of  adenoid  or  medullary 
cancer. 

In  other  cases  the  first  appearance  of  the  disease  is  in  the  shape  of 
little  papillary  excrescences  protruding  into  the  rectal  caliber,  but  con- 
nected with  the  mucous  and  submucous  tissues  by  an  indurated  base. 
These  tumors  always  result  in  adenoid  cancer.  They  bleed  easily  from 
the  beginning,  and  can  be  clearly  seen  through  the  sigmoidoscope.  In 
the  first  or  plaque-like  form,  ocular  examination  reveals  only  a  slightly 
congested,  thickened,  and  smoother  condition  of  the  mucous  membrane 
over  the  deposit.  In  scirrhus  one  observes  in  an  early  examination  a  sort 
of  annular  deposit  in  the  submucosa  resembling  very  closely  a  simple 
fibrous  stricture  of  the  gut.  It  is  almost  impossible  to  diagnose  car- 
cinoma of  this  tjTpe  in  the  latent  stage.  The  symptoms  are  those  of 
obstipation,  gradually  increasing,  with  or  without  bloody  or  mucous  dis- 
charges. The  history  of  the  case  may  be  of  diagnostic  importance,  for 
inflammatory  strictures  are  nearly  always  preceded  by  some  traumatism, 
ulceration,  and  suppuration,  whereas  this  tv^pe  of  carcinoma  is  not  ordi- 
narily preceded  by  such  processes.  While  in  this  latent  period  the  diag- 
nosis of  malignant  disease  is  often  quite  uncertain,  wide  clinical  experi- 
ence and  careful  observation  over  certain  periods  of  time  will  enable 
one  to  recognize  the  condition  before  it  arrives  at  an  incurable  stage. 

In  the  active  or  proliferative  stage  the  symptoms  are  more  marked. 
In  scirrhus  or  annular  carcinoma,  which  is  chiefly  met  with  in  the  upper 
rectum  and  sigmoid,  gradually  increasing  constipation  is  the  t}^ical 
S5Tnptom.  There  may  be  colicky  pains  in  the  stomach  or  upper  portions 
of  the  intestine,  aching  in  the  sacral  region,  and  occasionally  there  is  a 
sharp,  cutting  pain  at  the  seat  of  the  growth.  As  a  rule,  however,  pain 
is  not  a  prominent  feature  at  this  period  or  in  this  type  of  the  disease. 


774  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

A  slight  mucous  discharge,  occasionally  tinged  with  flecks  of  blood, 
appears  in  this  stage,  and  there  may  be  an  accumulation  of  gases  in  the 
intestine  causing  tympanites.  As  the  growth  increases  and  the  caliber 
of  the  gut  is  more  and  more  encroached  upon,  obstruction  to  the  faecal 
passages  becomes  more  marked,  friction  is  more  noticeable,  and  the 
amount  of  blood  in  the  discharges  becomes  more  abundant. 

At  this  time  a  certain  amount  of  procidentia  or  intussusception  of 
the  affected  into  the  lower  portion  of  the  gut  will  occur.  This  practically 
produces  a  procidentia  of  the  third  degree,  in  which  the  neoplasm  forms 
the  lowest  portion  of  the  prolapse,  and  around  it  there  exists  a  circular 
cul-de-sac  or  sulcus  into  which  the  finger  or  bougie  will  slip  instead  of 
into  the  caliber  of  the  gut.  Examination  with  the  proctoscope  under 
these  circumstances  exhibits  a  mass  in  the  center  of  the  intestinal  caliber 
resembling  very  much  the  cervix  uteri.  The  lumen  of  the  gut  at  the 
strictured  point  usually  appears  as  a  lateral  slit,  and  the  mucous  mem- 
brane may  or  may  not  be  ulcerated  according  to  the  stage  of  the  disease 
and  the  amount  of  traumatism  to  which  it  has  been  subjected  by  the 
passage  of  hard  faecal  material.  When  within  reach  such  a  growth  im- 
parts to  the  finger  the  sensation  of  a  dense,  inelastic,  nodular  mass,  in 
the  center  of  which  there  is  a  greater  or  less  lumen.  With  the  finger 
of  one  hand  in  the  rectum  and  the  other  pressing  down  upon  the 
abdomen,  such  growths  may  sometimes  be  brought  within  reach,  whereas 
they  can  not  be  felt  by  the  ordinary  methods  of  digital  examination. 

The  adenoid  or  medullary  cancer  presents  an  entirely  different  pic- 
ture in  this  second  stage.  Constipation  may  or  may  not  be  one  of  its 
features.  Exasperating,  frequent  calls  to  defecate,  resulting  in  the 
passage  of  small  amounts  of  gas  and  mucus,  with  or  without  blood,  are 
the  principal  symptoms.  The  patient  may  have  to  attend  the  toilet 
fifteen  or  twenty  times  a  day  and  as  many  times  at  night,  and  yet  have 
no  satisfactory  movement.  Ordinarily  this  tendency  to  diarrhoea  is 
quiescent  during  the  night,  but  the  patient  must  repair  to  the  toilet 
immediately  upon  rising  in  the  morning.  This  constitutes  what  is 
ordinarily  known  as  morning  diarrhoea,  and  it  is  one  of  the  most  char- 
acteristic features  of  malignant  disease  of  the  rectum  and  sigmoid. 
The  first  one  or  two  passages  after  the  patient  arises  consist  in  nothing 
more  than  mucus,  blood,  and  pus;  after  this  the  patient  may  have  a 
very  satisfactory  faecal  movement,  and  then  during  the  rest  of  the  day 
he  is  annoyed  by  the  teasing,  unsatisfactory  calls  to  stool.  The  haemor- 
rhages may  be  constant  and  slight,  or  periodical  and  exhausting;  the 
blood  is  sometimes  black  and  decomposed,  at  others  bright  red.  In  the 
first  instance  it  generally  comes  from  neoplasms  of  the  sigmoid  or  high 
up  in  the  rectum;  in  the  latter  from  those  in  the  ampulla  or  sub- 
peritoneal area. 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA         775 


Pain  in  these  cases  is  marked.  It  may  be  intermittent  or  constant; 
dull,  vague,  and  shooting  through  the  pelvis  or  down  the  extremities, 
or  it  may  be  sharp,  stabbing,  or  burning.  It  is  often  influenced  by 
posture.  Some  cases  are  only  comfortable  when  lying  down,  others  can 
not  sit  with  any  comfort,  and  still  others  are  more  free  from  pain  when 
standing  up.  It  may  only  occur  at  or  after  defecation,  but  in  certain 
eases  this  function  seems  to  have  no  influence  upon  it.  In  cases  in 
which  the  sphincters  are  involved,  the  pain  is  ordinarily  greater  than 
where  the  cancer  is  higher  up.  In  these  instances  incontinence  of  faeces 
is  sometimes  noted,  owing 
to  the  infiltration  of  the 
muscle  and  its  consequent 
inability  to  contract. 

Constitutional  symp- 
toms, such  as  loss  of  appe- 
tite and  weight,  anaemia, 
rapid  heart  action,  and  in- 
creasing sallowness  of  the 
skin,  begin  to  manifest 
themselves  at  this  period, 
and  local  examination  ex- 
hibits a  variety  of  con- 
ditions. Sometimes  a 
smooth,  hard,  lobulated 
mass  protrudes  into  the 
rectum,  involving  the  en- 
tire circumference  of  the 
gut,  and  almost  occluding 
its  caliber;  at  others  the 
mass  is  equally  as  promi- 
nent, but  attached  to  a 
limited  portion  of  the  cir- 
cumference. Sometimes  the 
finger  comes  in  contact  with  a  proliferating  cauliflower-like  groAvth, 
slimy  to  the  touch,  and  between  the  lobes  of  which  it  can  be  in- 
sinuated; at  other  times  there  is  no  protrusion  into  the  gut,  but  a 
distinct  narrowing  of  its  caliber  by  an  indurated  deposit  extending 
around  the  gut  or  involving  only  a  portion  of  its  circumference,  in  the 
center  of  which  is  a  deep,  excavating  ulcer,  the  edges  of  which  are  sharp, 
hard,  and  scalloped  (Fig.  255). 

In  the  medullary  type  the  symptoms  are  more  severe,  the  pain  is 
greater,  the  discharges  more  profuse,  the  loss  of  flesh  and  strength  more 
rapid,  and  the  involvement  of  neighboring  organs  occurs  at  earlier  peri- 


FiG.  255. — Medullaby  Cabcdtoma  of  the  Rectum. 


776  THE  ANUS,   RECTUM,   AND  PELVIC  COLON 

ods.  Digital  examination  in  these  cases  reveals  a  dense  ulcerated  mass, 
the  edges  of  which  are  sharply  defined  and  surround  a  deep  crater-like 
cavity.  Occasionally  the  finger  comes  in  contact  with  a  soft,  pulpy, 
brain-like  mass,  more  or  less  isolated,  friable,  and  easily  breaking  down 
upon  pressure.  Finally,  one  observes  at  times  a  moist,  slimy,  soft  con- 
dition of  the  mucous  membrane,  accompanied  by  a  fluctuation  in  the 
walls  of  the  gut,  together  with  a  distinct  reduction  in  its  caliber.  All 
of  these  conditions  are  associated  with  a  foetid,  gangrenous,  disgust- 
ing odor,  which  Allingham  states  is  pathognomonic  of  the  disease.  The 
proctoscope  reveals  the  appearance  of  these  conditions  in  a  remarkable 
manner,  and  in  sites  in  which  it  is  impossible  to  feel  them  with  the 
finger.  It  may  show  in  the  adenoid  variety  a  smooth,  lobulated  tumor 
protruding  into  the  rectum,  covered  by  dark-red  congested  mucous  mem- 
brane with  enlarged  veins  and  bathed  in  viscid  mucus,  or  a  condyloma- 
tous  growth,  grayish-white  in  its  appearance,  secreting  a  muco-purulent 
fluid  and  bleeding  easily  upon  touch.-  In  medullary  cancers  it  exhibits 
a  dense,  irregular,  ulcerated  mass  protruding  into  the  rectum,  or  a  deep, 
excavating  ulcer,  with  sharp,  well-defined  borders  and  bright-red  prolif- 
erating granulation,  or  dull,  grayish,  and  sloughing.  Finally,  in  the 
gelatiniform  or  colloid  types  one  sees  a  grayish  or  bright-red  cedema- 
tous  mucous  membrane,  lobulated  or  elevated  at  points  by  nodules  under- 
neath, and  secreting  an  abundant  sanious  mucus. 

In  the  third  or  degenerative  stage,  the  symptoms  are  all  more  marked. 
The  digestion  is  exceedingly  deranged,  the  anaemia  becomes  excessive, 
the  skin  is  pale,  dry,  parchment-like  and  covered  with  fine  silvery  scales. 
General  debility  progresses,  and  the  countenance  of  the  patient  exhibits 
an  anxious,  foreboding  appearance.  The  haemorrhages  become  more 
frequent  and  abundant,  the  diarrhoea  is  more  distressing,  and  the  faecal 
passages  less  satisfactory.  The  pains  are  more  acute  and  more  constant, 
the  mucous  discharges  are  supplanted  by  excessive  purulent  secretions, 
and  the  odor  from  the  parts  becomes  more  and  more  offensive.  On  the 
whole,  the  patient  presents  a  typical  picture  of  mild  septicaemia. 

With  these  one  observes  in  this  stage  other  symptoms  connected  with 
the  different  organs  of  the  body,  such  as  the  genito-urinary,  glandular, 
and  secretive  organs.  Anuria  and  dysuria  are  very  frequent  complica- 
tions, either  constant  or  periodical.  The  total  suppression  of  urine  may 
occur  through  involvement  of  the  ureters  or  of  the  kidneys  themselves. 
Irregularities  of  the  menstrual  functions  are  frequently  observed,  and 
hepatic  derangements  are  among  the  most  frequent  complications.  Ab- 
solute obstruction  of  the  intestine  rarely  if  ever  occurs  from  carcinoma 
of  the  rectum  itself.  This  mal^'  be  due  to  the  amplitude  of  the  rectal 
ampulla,  to  the  marked  tendency  of  growths  to  ulcerate  in  this  portion, 
or,  finally,  to  the  fact  that  the  parts  are  most  directly  influenced  by 


MALIGNANT   NEOPLASMS— CARCINOMA  AND   SARCOMA  (  (  ( 

enemata.  In  the  writer's  opinion^  it  is  cMefly  due  to  tlie  fact  that  the 
types  of  cancer  which  occur  most  frequently  in  the  rectum  (adenoid 
and  medullary)  are  soft  and  compressible  or  friable,  and  they  degen- 
erate or  ulcerate  chiefly  upon  the  surface,  thus  keeping  the  caliber  of 
the  gut  open.  He  has  never  observed  a  case  of  complete  obstruction 
from  carcinoma  of  the  rectum.  On  the  other  hand,  this  accident  is 
always  imminent  in  carcinoma  of  the  sigmoid  flexure,  owing  to  the  fact 
that  the  t^-pe  of  growth  which  occurs  in  this  location  is  often  scirrhus, 
which  does  not  ulcerate  or  degenerate  easily,  but  constantly  and  per- 
sistently contracts  the  caliber  of  the  gut  in  which  it  occurs.  The  ob- 
struction even  here  is  not  usually  absolute,  but  due  to  the  impaction  of 
some  foreign  body  or  hard  fsecal  mass  in  the  narrowed  caliber.  Above 
and  below  carcinoma  in  the  intestine  the  wall  of  the  gut  is  inflamed 
and  very  thin.  Ordinarily  marked  ulceration  is  found  above  the 
stricture,  and  it  is  at  this  site  that  rupture  or  perforation  takes  place, 
if  at  all. 

Aside  from  the  reflex  disturbances  of  digestion  referred  to  hereto- 
fore, there  are  other  complicating  symptoms  which  arise  in  the  course 
of  carcinoma  of  these  organs;  among  these  auto-infection  or  mild  septi- 
caemia is  the  most  constant.  This  may  be  brought  about  by  retention 
and  putrefaction  of  faecal  material  above  the  neoplasm,  or  it  may  be 
induced  by  traumatic  lesions  of  the  mucous  membrane  from  the  passage 
of  hard  fsecal  material,  which  lesions  become  infected.  In  the  first  in- 
stance this  sepsis  manifests  itself  as  a  sort  of  malaise  with  slightly 
elevated  evening  temperature,  lack  of  energy,  and  loss  of  strength.  In 
the  second,  it  occurs  as  periodical  crises  with  chill,  fever,  and  great 
exhaustion.  This  type  resembles  very  much  the  sepsis  of  surgical  kid- 
ney in  its  early  stages.  In  other  cases  perirectal  abscesses  develop,  which 
sometimes  result  in  fistula  or  perforation  into  other  organs,  such  as  the 
bladder,  vagina,  or  peritoneal  cavity.  These  cases  are  also  accompanied 
with  high  temperature,  chills,  and  septic  sjonptoms.  They  have  a  tend- 
ency to  result  in  extensive  gangrene  and  sloughing  similar  to  that  seen 
in  idiopathic  periproctitis. 

Aside  from  these  septic  complications,  inflammatory  conditions 
around  the  neoplasm  and  between  the  rectum  and  other  organs  are 
frequently  met  with.  The  bladder,  prostate,  and  seminal  vesicles  may 
all  become  attached  to  the  carcinomatous  rectum  through  inflammatory 
processes  without  being  involved  in  the  neoplastic  change.  The  author 
has  twice  removed  portions  of  the  prostatic  gland  and  seminal  vesicles 
in  excision  of  cancer  of  the  rectum,  and  found  that  these  organs  were 
entirely  free  from  carcinosis.  The  same  may  be  said  with  regard  to  the 
vaginal  sfeptum.  Inflammatory  deposit  here  may  cause  a  matting  to- 
gether of  the  walls  of  the  two  cavities  without  any  carcinomatous  change 


778  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

taking  place  in  the  parts;  indeed,  this  saeptmn  may  be  perforated  through 
simple  destructive  ulceration  below  the  carcinoma.  In  one  instance  in 
which  this  took  place  the  author  was  unable,  after  various  examinations, 
to  find  that  the  rectum  or  vaginal  wall  at  the  site  of  the  ulcer  was  in- 
volved in  the  carcinomatous  process  which  existed  at  a  higher  level. 
The  peritoneal  cul-de-sac  may  also  become  obliterated  by  this  perirectal 
inflammation;  under  these  circumstances  the  opening  of  the  cavity  dur- 
ing extirpation  is  rendered  very  difficult.  These  facts  are  important, 
because  they  indicate  that  the  attachment  of  a  carcinomatous  rectum 
to  any  of  these  organs  is  not  pathognomonic  evidence  of  their  involve- 
ment in  the  malignant  processes.  Thus,  the  author  has  seen  3  cases  in 
which  the  rectum,  uterus,  and  ovaries  were  all  removed  for  carcinoma, 
and  yet  upon  the  most  careful  examination  no  involvement  whatever 
of  the  uterine  organs  could  be  determined.  In  two  other  instances  in 
which  the  peritoneal  cul-de-sac  was  obliterated  and  the  rectimi  attached 
to  the  uterus,  this  adhesion  was  broken  up  and  the  rectum  extirpated, 
and  no  carcinosis  of  the  uterine  organs  followed.  It  is  admitted  that 
all  of  these  organs  may  be  involved  by  extension  in  continuity  of  the 
carcinoma,  but  adhesion  does  not  always  indicate  involvement  in  the 
malignant  process. 

Lines  of  Extension. — Carcinoma  of  these  organs  extends,  by  continu- 
ity, through  the  lymphatics,  and  possibly  through  the  blood.  The 
lines  and  method  of  extension  are  largely  governed  bj'  the  seat  of  the 
disease. 

In  anal  cancer  the  disease  usually  extends,  by  continuity  in  the  skin 
surrounding  the  anus,  into  the  scrotum,  vulva,  vagina,  the  ischio-rectal 
fossa,  and  sometimes  upward  into  the  rectum.  Occasionally  in  these 
cases  fistulous  tracts  develop  which  are  found  to  partake  of  the  epitheli- 
omatous  nature  of  the  growth.  Lymphatic  extension  of  cancer  from  this 
region  travels  in  the  line  of  the  inguinal  vessels  and  glands.  Both  the 
superior  and  inferior  chains  may  be  involved.  Quenu  and  Hartmann 
have  called  attention  to  the  fact  that  when  these  cancers  invade  the 
ischio-rectal  fossa,  they  may  extend  along  the  line  of  the  middle  haemor- 
rhoidal  lymjjhatics,  thus  involving  the  hypogastric  chain  of  glands.  The 
glands  always  partake  of  the  nature  of  the  original  growth,  which  is 
usually  squamous  epithelioma  in  this  region,  but  it  may  be  of  the  adenoid 
type.  Occasionally  the  glands  become  enlarged  and  tender  through 
infection  without  presenting  any  carcinomatous  changes. 

Cancer  in  the  subperitoneal  portion  of  the  rectum  extends  by  con- 
tinuity to  the  prostate,  urethra,  seminal  vesicles,  bladder,  vagina,  uterus, 
and  coccyx  (Quenu  and  Hartmann,  Pasteau,  Schoening,  Leube,  Fayard, 
Eabe).  Ganglionic  extension  occurs  in  the  retro-rectal  and  hypogastric 
chains.     The  lateral  vertebral  lymphatics  may  also  become  involved 


MALIGNANT   NEOPLASMS— CARCINOMA  AND  SARCOMA         779 

from  cancer  in  this  location  (Ball,  Fayard).  In  some  cases  the  ureters 
seem  to  become  involved  through  this  process,  and  not  by  extension 
(Fayard,  Thesis,  Lyons,  1891,  p.  60). 

Cancer  of  the  supraperitoneal  portion  extends  by  continuity  to  the 
bones  of  the  pelvis,  to  the  peritonsuni,  and  to  the  uterus,  bladder,  or 
omentum.  In  one  instance,  in  which  the  abdomen  was  opened  to  deter- 
mine the  extent  of  the  disease,  the  whole  peritonffium  and  greater  omen- 
tum was  studded  with  myriads  of  little  gelatinoid  nodules,  which  proved 
to  be  colloid  cancers.  Ganglionic  extension  from  these  growths  is  not 
frequent.  When  it  occurs  it  extends  along  the  antero-vertebral  chain, 
involving  sometimes  the  hypogastric  glands. 

Metastatic  deposit  or  generalization  of  the  cancer  may  occur  from 
carcinoma  in  any  of  these  locations.  It  is  not  the  rule,  however.  The 
liver  is  the  organ  generally  affected.  Whether  this  occurs  through  the 
blood-vessels  or  through  the  lymphatics  is  not  positively  known.  Hoche- 
negg  and  Einne  (Wiener  klin.  Woch.,  1889,  Nos.  26,  27,  28)  have 
collected  a  number  of  cases  in  which  this  organ  was  attacked  both 
before  and  after  extirpation.  The  author  has  observed  it  in  6  cases,  2 
of  which  were  recurrences  after  operation.  The  pancreas  (Cripps,  op. 
cit.,  p.  372),  the  lungs  (Luys,  Soc.  anat.,  February  5,  1897;  Quenu 
and  Hartmann,  op.  cit.,  vol.  ii,  p.  137),  the  ovaries  and  skin,  the  kidneys 
(Schuh,  Abhandlung  d.  Chirurgie  und  Operat.  Lehre,  Wien,  1867), 
and  the  axillary  and  subclavicular  glands  may  all  become  involved. 
Sometimes  the  small  intestine  becomes  attached  to  the  rectum  or  sigmoid 
affected  with  carcinoma,  and  may  become  involved  in  the  growth. 
The  author  has  seen  one  case  in  which  this  occurred  from  carcinoma  of 
the  rectum,  the  small  intestine  becoming  adherent  and  involved  in 
ihe  peritoneal  cul-de-sac;  and  another  in  carcinoma  of  the  sigmoid, 
in  which  both  portions  of  the  intestine  were  attached  to  the  brim  of  the 
pelvis,  the  periosteum  of  which  was  involved  in  the  growth,  together 
with  the  left  iliac  vessels,  Kirchoff  and  Beckel  (Quenu  and  Hartmann, 
op.  cit.,  vol.  li,  p.  139)  have  related  cases  in  which  this  complication  has 
occurred. 

Diagnosis. — Carcinoma  is  not  likely  to  be  confounded  with  any  other 
condition  of  the  rectum  and  sigmoid  than  multiple  adenomata,  papilloma, 
sarcoma,  proliferating  proctitis,  and  fibrous  stricture.  The  extreme  tend- 
ency of  the  first  two  to  be  transformed  into,  or  when  removed  to  recur 
in  the  form  of  carcinoma,  renders  it  wise  to  treat  them  as  such  in  the 
beginning.  From  these  facts  differentiation  in  these  cases  derives  a 
reduced  importance  so  far  as  treatment  is  concerned.  For  the  purposes 
of  prognosis,  however,  the  neoplasms  should  be  distinguished  as  far  as 
possible,  for  one  is  much  more  justified  in  giving  a  favorable  opinion 
in  cases  in  which  malignancy  has  not  already  appeared  than  where  it 


780 


THE   ANUS,   RECTUM,   AND   PELVIC   COLON 


has.     The  distinctive  features  are  briefly  enumerated  in  the  following 
columns: 


Adenoma 

Generally  in  adult  life, 
but  may  occur  in  children. 

More  frequent  in  fe- 
males. 

Distributed  over  large 
areas,  even  the  entire 
colon. 

Tumors  vary  greatly  in 
size,  and  rarely  coalesce. 

They  are  soft  and  elastic 
to  the  touch. 

Attached  to  the  rectal 
wall  by  a  pedicle  or  base 
of  normal  mucous  or  sub- 
mucous tissue. 

Diarrhoea  and  hemor- 
rhage are  the  earliest 
symptoms. 


The  odor  of  the  secre- 
tions is  not  unusually  of- 
fensive. 


Papilloma 

Occurs  in  adult  and  ad- 
vanced life,  rarely  if  ever 
seen  in  cliildren. 

No  predominance  in 
either  sex. 

May  be  single  or  two  or 
three  in  number  closely 
aggregated. 

May  attain  very  large 
proportions. 

Soft  and  shaggy  or  vil- 
lous to  the  touch. 

Attached  to  the  rectal 
wall  very  superficially. 
The  pedicle  may  be  long 
and  the  base  indurated. 

Discharge  a  peculiar 
gluey  mucus.  Htemor- 
rhages  are  irregular  and 
periodic.  Constipation  is 
more  frequent  than  diar- 
rhoea. 

Anaemia  and  physical 
exhaustion  come  on  quite 
early. 


No  particular  odor. 


Carcinoma 

LTsually  in  advanced 
life,  but  may  occur  in 
youth. 

More  frequent  in  men. 

Is  generally  limited  in 
area,  but  may  involve  the 
entire  rectum. 

Base  is  always  indura- 
ted, and  involves  the  en- 
tire thickness  of  the  gut. 


Constipation  is  the  rule 
in  the  early  stages  ;  diar- 
rhoea in  the  later.  Mu- 
cous discharges  precede 
those  of  pus  and  blood. 

Constitutional  symp- 
toms appear  after  tumor 
ulcerates. 

Extension  takes  place 
by  continuity,  metastasis, 
and  through  the  lymphat- 
ics. 

Odor  sui  generis. 


"WTiile  some  of  these  symptoms  are  similar  and  overlap  one  another, 
to  the  experienced  clinician  there  is  rarely  any  difficulty  in  distinguish- 
ing the  typical  growths.  In  those  transitory  stages,  where  the  benign 
is  undergoing  transformation  into  the  malignant  type,  nothing  short  of 
complete  extirpation  and  thorough  examination  of  the  entire  growth 
can  absolutely  distinguish  one  from  the  other.  In  doubtful  cases,  indeed 
in  all  cases,  it  is  wise  to  remove  a  section  of  the  growth  for  microscopic 
examination,  but  one  should  not  place  too  much  confidence  in  negative 
reports  with  regard  to  malignancy.  The  growth  may  be  perfectly  be- 
nign in  that  portion  from  which  the  section  was  taken  and  markedly 
malignant  in  other  portions.  The  fault  is  not  with  the  methods  of  ex- 
amination or  with  the  pathologist;  it  lies  in  the  nature  of  the  neoplasms. 


MALIGNANT  NEOPLASMS— CARCINOMA  AND   SARCOMA 


rsi 


The  most  prominent  and  accessible  portions  of  these  growths  are  often 
benign^  while  the  deeper  portions  are  absolutel}^  malignant.  "We  main- 
tain this  from  numerous  experiences^  notwithstanding  it  is  claimed  that 
the  transformation  begins  on  the  surface.  AMiile,  therefore,  microscoiDic 
examination  is  of  great  assistance  in  corroborating  clinical  evidence,  it 
should  not  shake  the  clinical  conviction  of  an  experienced  surgeon  as 
to  malignancy  in  one  of  these  cases.  The  author  has  removed  5  neo- 
plasms of  the  rectum  which  had  been  pronounced  benign  from  micro- 
scopic examination  of  the  sections  taken  for  diagnosis,  and  has  in  each 
instance  found  his  clinical  conviction  corroborated  by  more  complete 
and  thorough  microscopic  examination  of  the  growth  after  its  removal. 

It  is  important  in  obtaining  specimens  for  microscopic  examination 
not  to  crush  them.  This  can  be  done  by  use  of  nasal  scissors  (Fig.  256) 
or  the  specimen  forceps  (Fig.  254).    The  bite  of  the  latter  consists  in 


Fig.  256. — Scissors  eiiployed  foe  obtaining 
Specihens  of  Rectal  Geowths. 


two  elliptical  Yolkmann  spoons,  which  cut  out  the  specimen  and  hold  it 
in  the  cavity  formed  by  their  approximation;  the  instrument  is  12  inches 
long,  and  was  devised  for  operation  through  the  sigmoidoscope.  By  it 
specimens  may  be  obtained  from  any  part  of  the  pelvic  colon. 

Between  carcinoma  and  proliferating  proctitis  the  diagnosis  is  not 
very  diflEicult,  although  many  of  the  symptoms  are  similar.  In  the  latter 
there  is  generally  a  history  or  other  manifestations  of  syphilis;  the  dis- 
ease is  uniformly  distributed  throughout  the  rectum;  diarrhoea  is  present 
from  the  beginning,  and  the  discharge  of  muco-pus  is  abundant;  there 
is  little  pain,  and  the  protruding  granulations  are  soft  to  the  touch  and 
without  any  indurated  edges.  These  symptoms  are  sufficient  to  distin- 
guish it  from  carcinoma,  but  one  may  still  further  rely  upon  the  pathog- 
nomonic odor  in  the  latter  disease. 


782  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

Between  scirrhous  cancer  and  fibrons  stricture  it  is  almost  impossible 
to  make  a  diagnosis,  except  by  complete  excision  and  microscopic  exam- 
ination. The  early  symptoms  of  the  t«'o  are  practically  the  same.  In 
fibrous  stricture  there  is  usually  a  history  of  inflammation  or  ulceration, 
but  this  may  also  be  true  in  scirrhous  carcinoma.  Scirrhus  rarely  occurs 
in  the  rectum,  and  fibrous  stricture  is  quite  as  rare  in  the  sigmoid.  Thus 
the  site  of  the  disease  may  be  of  importance,  but  it  is  not  absolutely 
diagnostic.  Where  the  growth  can  be  easily  reached  a  nodular  condi- 
tion may  be  felt  in  scirrhus  which  is  not  present  in  pure  fibrous  stricture. 
Glandular  involvement  is  sometimes  spoken  of  as  a  diagnostic  symptom, 
but  this  occurs  very  tardily  even  in  scirrhus.  Through  the  proctoscope 
the  mucous  membrane  over  scirrhus  appears  congested,  thickened,  or 
ulcerated;  over  fibrous  stricture  it  is  pale,  smooth,  shining,  and  rarely 
ulcerated. 

The  fact  that  carcinoma  may  present  so  few  subjective  symptoms, 
all  of  which  are  explicable  by  other  conditions,  emphasizes  the  impor- 
tance of  local  examination  in  all  cases  in  which  diarrhoea,  constipation, 
obscure  digestive  derangements,  pain  in  the  sacral  region,  and  discharges 
of  mucus,  blood,  and  pus  from  the  anus  exist.  The  means  of  such 
examinations  are  the  finger  and  pneumatic  proctoscope.  So  far  as  it 
goes,  the  finger  is  by  far  the  most  satisfactory,  but  above  4^  inches  one 
must  depend  upon  the  instrument.  Ordinary  tubes,  specula,  sounds, 
and  bougies  should  never  be  employed  in  these  cases,  for  the  operator 
should  always  be  able  to  see  the  space  into  which  the  instrument  is 
directed.  Even  the  introduction  of  the  finger  should  be  made  with  the 
greatest  gentleness,  for  the  weakened  walls  of  the  gut  may  be  easily  torn. 
"With  the  pneumatic  proctoscope,  after  the  sphincter  has  been  passed, 
the  gut  is  distended  by  air  and  the  tube  is  pushed  upward  through  the 
dilated  caliber  without  coming  in  contact  with  the  walls  of  the  gut  until 
the  tumor  or  contraction  is  reached.  The  degree  of  distention  is  never 
so  great  as  to  endanger  the  integrity  of  the  walls,  for  the  air  either 
escapes  upward  into  the  intestine  or  outward  through  the  anus  when- 
ever any  tension  is  produced.  By  this  means  the  exact  location  and 
appearance  of  the  disease  may  be  determined  up  to  the  highest  limits 
of  the  sigmoid  flexure.  In  Plates  ^T^I  and  YIII  are  illustrated  the  ap- 
pearance of  two  carcinomas  of  the  sigmoid.  The  small,  round  figures 
show  the  growths  as  they  appeared  through  the  proctoscope;  the  larger 
ones  show  their  appearance  immediately  after  excision.  The  importance 
of  this  method  of  diagnosis  in  tumors  situated  above  the  reach  of  the 
finger  can  not  be  overestimated. 

In  the  diagnosis  of  cancer,  either  by  the  finger  or  the  proctoscope, 
it  must  always  be  borne  in  mind  that  the  integrity  of  the  mucous  mem- 
brane does  not  in  any  wise  indicate  the  limits  of  the  disease.    Carcino- 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA        T83 

ma  spreads  in  the  submucous  and  muscular  walls  of  the  gut,  and  the 
mucous  membrane  may  be  perfectly  healthy  over  large  areas  in  which 
the  deeper  tissues  are  involved  in  the  carcinomatous  process. 

Epithelioma  of  the  anus  may  be  mistaken  for  fissure,  condyloma,  or 
tubercular  deposits.  From  fissure  they  are  distinguished  by  their  indura- 
tion, their  tendency  to  scab  over  and  extend  in  area,  and  by  their  seat, 
which  is  usually  upon  the  folds  and  not  between  them.  From  condyloma 
they  may  be  distinguished  by  their  density,  disposition  to  bleed,  and 
indurated  base.  From  tubercular  deposits  they  are  distinguished  by 
their  irregular  shape,  bright-red  color,  and  lack  of  any  tendency  to  un- 
dermine the  skin.  Occasionally,  where  an  epithelioma  develops  from  a 
prolapsing  hfemorrhoid,  it  may  be  difficult  to  distinguish  it  from  the 
granular  condition  which  is  sometimes  seen  on  these  hj'pertrophies. 
Finally,  as  Quenu  and  Hartmann  have  pointed  out,  one  should  bear  in 
mind  the  resemblance  between  these  neoplasms  and  the  condition  pro- 
duced by  actinomycosis.  The  diagnosis  in  all  these  anal  cases  may  be 
positively  established  by  microscopic  examination,  which  will  reveal  the 
epithelial  nature  of  the  cancer  whenever  it  exists. 

It  has  been  recommended  from  time  to  time  that  in  cases  of  cancer 
situated  high  up  in  the  rectum,  the  entire  hand  should  be  introduced 
for  the  purposes  of  diagnosis.  The  author  is  convinced  that  this  is  not 
only  a  dangerous,  but  useless  procedure,  and  does  not  hesitate  to  con- 
demn the  practice.  Instrumental  examination  has  reached  such  a  stage 
of  perfection  that  this  method  can  no  longer  be  countenanced. 

Finally,  one  should  not  forget  to  mention  and  recommend  laparotomy 
as  a  means  of  diagnosis  in  these  cases.  This  procedure  is  not  of  so  much 
importance  to  determine  the  existence  as  the  extent  of  a  neoplasm.  It 
is,  in  fact,  one  of  the  chief  means  of  deciding  upon  the  operable  character 
of  high  carcinomas.  It  not  only  furnishes  an  accurate  knowledge  of  the 
condition  of  the  growth  and  the  extent  of  its  involvement  of  other  or- 
gans, but  enables  one  to  determine  the  ganglionic  extension  along  the 
vertebral  chains.  The  incision  for  such  an  examination  should  always  be 
made  in  the  same  line  as  that  for  inguinal  colotomy,  in  order  that  if  one 
deems  it  necessary  he  may  at  the  same  time  produce  an  artificial  anus, 
either  temporary,  with  a  view  to  excise  the  growth,  or  permanent  in  case 
the  conditions  demand  it.  It  is  not  sufficient  simply  to  introduce  the  in- 
dex finger  in  these  cases,  but  the  incision  should  be  made  large  enough  to 
admit  the  whole  hand,  which  should  be  introduced  in  order  to  examine 
the  entire  pelvic  cavity,  the  prevertebral  glands,  and  also  the  surface  of 
the  liver.  By  this  means  the  author  has  been  able  twice  to  determine 
the  uselessness  of  any  attempts  at  removal  of  the  carcinoma,  and  under 
modern  aseptic  precautions  the  procedure  may  be  said  to  be  practically 
without  danger. 


784  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

Treatment. — The  treatment  of  carcinoma  of  these  organs  is  the  most 
serious  problem  that  the  rectal  surgeon  ever  has  to  face.  The  majority 
of  these  cases  in  the  past  have  ended  fatally  regardless  of  what  method 
has  been  employed.  In  a  few  an  apparent  cure  has  been  obtained,  but 
the  percentage  is  small.  The  following  questions  must  be  answered  in 
every  case:  Is  there  reasonable  hope  of  cure  by  extirpation?  "Will  the 
patient's  life  and  usefulness  be  prolonged  by  this  operation,  and  his 
suiferings  be  relieved?  Or  will  these  ends  be  attained  in  a  greater  meas- 
ure by  palliative  methods,  such  as  irrigation,  curettage,  opium,  and,  if 
necessary,  an  artificial  anus  or  entero-anastomosis?  Between  these 
methods  of  treatment  the  profession  has  vibrated  for  the  past  three- 
quarters  of  a  centurj'. 

Before  the  introduction  of  aseptic  surgery  the  immediate  mortality 
from  extirpation  of  cancers  of  the  rectum  and  sigmoid  was  so  high  that 
many  surgeons  claimed  the  operation  was  never  justifiable.  !More  re- 
cently this  mortality  has  been  much  reduced,  and  many  of  those  who 
formerly  condemned  the  operation  now  favor  it  in  properly  selected 
cases.  If  the  ultimate  were  proportionately  as  good  as  the  immediate 
results,  few  surgeons  would  deny  patients  the  opportunity  of  radical 
cure  with  four  chances  out  of  five  in  their  favor.  Unfortunately,  re- 
currences in  situ  or  generalization  of  the  disease  has  proved  so  frequent 
after  these  operations  that  one  can  not  promise  with  any  degree  of 
certainty  that  the  gro^rth  will  not  return  within  one  or  two  years,  even 
if  the  patient  survives  radical  and  complete  extirpation.  The  experi- 
ence of  any  one  surgeon  is  always  too  limited  to  establish  reliable  con- 
clusions; some  few  have  operated  40,  50,  or  even  more  than  100  times, 
while  a  large  majority  who  report  their  cases  have  operated  from  1  to 
15  times.  The  only  just  estimate  of  this  procedure  must  be  deduced  by 
collecting  large  numbers  of  operations  done  by  different  surgeons.  By 
this  means  the  average  results,  in  average  hands,  and  in  an  average  class 
of  patients,  are  obtained. 

One  set  of  operators  confine  themselves  to  carcinomas  low  down  and 
removable  by  perineal  dissection;  the  mortality  in  these  cases  is  com- 
paratively low.  Another  class  pays  less  attention  to  the  elevation  of  the 
tumor,  but  confines  its  operations  to  those  cases  in  which  the  growth 
is  absolutely  confined  to  the  rectal  wall,  is  freely  movable,  and  has  not 
presented  local  symptoms  longer  than  six  months;  the  mortality  in  these 
cases  is  still  comparatively  small.  A  bolder  and  more  ambitious  class, 
however,  attacks  cases  regardless  of  the  attachments  of  the  tumors  to  the 
pelvic  organs  or  the  bony  frame;  in  this  class  the  inunediate  mortality 
and  the  percentage  of  early  recurrences  are  exceedingly  high.  The 
actual  facts  are  only  obtained  by  combining  the  results  of  all. 

The  author  and  his  associate.  Dr.  George  H.  Wellbrock,  have  col- 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA         785 

lected  from  literature  and  private  communications  a  total  of  1,578 
cases  of  extirpation  of  the  rectum  done  since  1880,  with  a  mortality  of 
319,  or  20.2  per  cent.  With  slight  differences  this  is  practically  the 
conclusion  of  Finet  (Exerese  dans  le  cancer  du  rectum,  Paris,  1896),  who 
collected  375  cases,  Carl  Vogel  (Deutsch.  Zeitsch.  f.  Chir.,  April  19, 
1901),  and  Hupp  (Med.  News,  September  28,  1901),  who  have  made 
similar  compilations.  In  a  summary  of  cases  made  in  1896  (Jour.  Amer. 
Med.  Ass'n,  1897),  drawn  largely  from  private  communications  and  num- 
bering 249  in  all,  the  author  showed  a  mortality  from  these  of  only  13.5 
per  cent,  and  firmly  believed  at  that  time  that  this  mortality  would  be 
materially  reduced  as  the  technique  of  the  operation  improved  and  our 
knowledge  of  how  to  select  operable  cases  increased.  He  is  compelled 
to  admit  at  present  that  these  hopes  have  not  been  realized.  The  mor- 
tality from  this  operation  in  the  past  five  years  appears  to  have  increased 
rather  than  decreased.  This  may  be  explained  by  the  following  facts: 
More  difficult  cases  are  operated  upon,  wider  dissection  for  the  removal 
of  glands  is  employed,  less  experienced  surgeons  are  attempting  the 
operation,  and  our  aseptic  technique  has  not  kept  pace  with  the  boldness 
of  operators.  Assuming,  however,  that  these  records  are  correct  and 
that  1  in  every  5  cases  of  cancer  of  the  rectum  dies  from  the  operation, 
there  would  still  be  few  who  would  hesitate  to  take  four  chances  in  five 
if  promised  a  radical  cure,  or  even  a  prolonged  extension  of  life.  But 
how  many  cases  are  actually  cured  by  extirpation,  and  to  what  extent 
is  life  prolonged  in  those  not  cured?  The  first  question  it  is  impossible 
to  answer,  because  there  is  such  a  diversity  of  opinion  in  regard  to  the 
period  after  extirpation  at  which  a  patient  may  be  said  to  be  cured. 
Formerly  it  was  held  that  when  a  patient,  having  been  operated  upon 
for  carcinoma,  had  survived  three  years  without  any  recurrence,  he 
might  be  said  to  be  well.  Recently,  however,  recurrences  have  been  ob- 
served six,  eight,  and  more  years  after  the  operation,  and  these  cases 
are  added  to  the  mortality  from  recurrences.  It  is  a  question  whether 
such  tardy  recurrences,  except  when  in  situ,  ought  not  to  be  considered 
new  developments  and  not  returns  of  the  old  disease.  These  cases  may 
be  left  out  of  account  from  the  fact  that  if  such  prolonged  freedom 
from  so  malignant  a  disease  can  be  obtained,  the  results  will  be  so  far 
in  advance  of  anything  which  can  be  accomplished  by  any  other  treat- 
ment that  no  comparison  can  be  instituted. 

When  it  is  recalled  that  the  disease  is  absolutely  fatal  when  left  alone, 
and  with  few  exceptions  within  one  year,  any  procedure  which  prolongs ^ 
life  two,  three,  or  more  years  must  be  considered  most  favorably,  espe- 
cially if  it  brings  comfort  and  relief  of  suffering  to  the  patient.  Treat- 
ment by  extirpation  arouses  hope  of  a  radical  cure,  and  thus  adds  buoy- 
ancy and  comfort  to  the  patient's  mind;  this  hope,  it  is  true,  is  bought 
50 


186 


THE  ANUS,   RECTUM,   AND  PELVIC  COLON 


at  a  price,  consisting  of  one  chance  in  five  of  deatli,  but  this  is  four 
times  as  many  chances  as  he  has  by  any  other  treatment.  It  offers  a 
prolongation  of  life,  as  the  average  length  of  life  following  extirpation 
is  two  years  and  seven  months,  calculated  from  602  cases  which  have 
been  followed;  this  is  nearly  three  times  as  long  as  that  given  by  non- 
operative  treatment,  and  almost  twice  as  long  as  that  furnished  by  the 
palliative  methods  of  colostomy  and  entero-anastomosis.  It  offers  a  dis- 
tinct chance  of  radical  cure,  of  life  without  recurrence  for  a  certain 
number  of  years.  The  percentage  of  such  cures  is  very  difficult  to  de- 
termine; that  observed  by  various  operators  is  far  from  uniform,  as  the 
following  table,  taken  from  Hupp's  article,  will  demonstrate.  This  is 
based  upon  the  assumption  that  three  full  years  without  recurrence 
constitute  a  cure  of  the  disease: 


Table 

Name. 

Number  of  operations. 

Cures. 

Percentage. 

Koeher 

35 
109 
63 
46 
53 
80 
95 
93 
66 

10 

16 

10 

8 

6 

11 

16 

12 

6 

28.5 

Czerny 

14.6 

Kronleiii 

16 

Bergmann 

Madelung  and  Garre 

17.4 
11.3 

Kraske 

13  7 

Kuster 

16  8 

Hoeneerer 

12  9 

Mikulicz 

9 

Average  percentage  of  cures. 

14.8 

It  is  to  be  observed  that  this  percentage  is  based  upon  the  total 
number  of  cases  operated,  and  not  upon  those  that  survived  the  imme- 
diate effects  of  operation.  To  these  may  be  added  the  experiences  of  the 
author,  who  has  operated  upon  32  cases,  with  an  immediate  mortality 
of  6 — 18.7  per  cent.  Of  the  other  26,  he  has  been  able  to  follow  16  of 
them  for  one  3'ear  or  more.  Of  these  there  are  living  without  recurrence, 
1  ten  years,  1  eight,  1  six,  2  (1  sarcoma)  five  and  one  half,  2  four,  9 
between  two  and  a  half  years  and  one  j'ear;  and  4  have  died  from  re- 
currences— 1  in  six  months,  1  in  eleven  months,  1  in  fourteen  months, 
and  1  in  two  years.  In  this  list  there  are  found  7  out  of  the  total  32 
cases  (21.8  per  cent)  who  have  survived  the  period  of  four  years  or  more. 
From  these  facts,  it  may  be  concluded  that  on  an  average  1  in  5  cases 
will  live  three  years  or  more  without  recurrence. 

What  does  the  operation  offer  in  relief  of  pain  and  maintenance  of 
normal  functions  so  long  as  the  patient  lives?  The  relief  of  pain  is 
complete  in  the  large  majority  of  cases.  In  the  statistics  furnished  by 
Hupp  absolute  sphincteric  control  was  retained  in  30  per  cent,  relative 
control  in  60  per  cent,  incontinence  in  10  per  cent  (taken  from  the 
personal  experience  of  Kronlein).    In  the  writer's  experience  in  26  cases 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA         T87 


which  survived  the  operation,  complete  incontinence  was  observed 
in  2,  partial  incontinence  in  7,  and  comparatively  perfect  sphincteric 
control  in  17.  All  the  latter  cases  were  instances  of  resection  by  the 
sacral  or  abdominal  methods  without  involvement  of  the  muscles.  Other 
complications,  such  as  stricture,  posterior  fistula,  and  abnormally  placed 
ani  do  occur,  but  they  are  of  such  minor  importance  compared  with  the 
disease  itself  that  they  need  scarcely  be  considered  except  in  relation  to 
the  different  methods  of  operating. 

While  the  average  length  of  life  made  up  from  the  entire  number 
of  operations  performed  is  comparatively  small,  there  are  numerous  in- 
stances in  which  the  operation  has  been  followed  by  no  recurrence  in 
long  periods.  The  following  table  brings  this  out  in  an  interesting 
manner: 

Table 


Name. 

Number  of  cases. 

Number  of  years  witbout  recurrence. 

Cripps 

2 

2 
2 

4 

5 

6 
12 

3 

6 

8 

7 

6 

8 

4 

5 

6 

8 
10 
14 
16 

6 

8 

4 

5 

7 

7 

7 

7 

4 

3 
10 

8 

6 

5i 
4 

'< 

«' 

Quenu 

i' 

J.  Boeckel 

<< 

Kocher 

10      " 

<< 

5       " 

w 

<> 

<£ 

<< 

Ball 

Konig 

Hildebrand 

Reclus 

Caspersohn 

Labe 

Richelot 

Keen 

6      " 

Author 

<t 

a 

" 

There  are  no  statistics  to  determine  the  comparative  results  of  opera- 
tions done  early  in  the  course  of  the  disease  and  late  in  its  development. 
Personal  experience  and  the  meager  reports  in  published  cases  show  that 
the  longer  the  symptoms  have  existed  the  less  chance  will  there  be  of 


788  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

immediate  or  permanent  recovery.  A  fact  of  much  more  im})ortance 
than  this,  however,  in  regard  to  prognosis  is,  that  the  younger  the  pa- 
tient the  less  are  the  chances  of  recovery,  and  each  year  we  are  seeing 
more  cases  in  early  life.  In  the  1,578  cases  studied,  those  in  which  the 
age  is  given  show  a  gradual  decrease  in  mortality  and  recurrence  as  the 
ages  increase.  Not  a  single  case  of  radical  cure  has  been  reported  under 
the  age  of  twenty-five  years.  Under  thirty  years  of  age  the  immediate 
mortality  is  over  30  per  cent,  and  the  recurrences  approximate  60  per 
cent.  Fifty  to  sixty  years  seems  to  be  the  most  favorable  age  for  opera- 
tion. The  mortality  in  these  cases  is  about  13  per  cent,  and  the  recur- 
rences are  less  than  40  per  cent. 

Causes  of  Death  following  Extirpation. — A  study  of  the  causes  of 
death  shows  that  there  is  reason  to  hope  the  high  mortality  from  this 
operation  will  some  day  be  reduced. 

The  causes  of  death,  as  determined  by  Hupp  in  a  collection  of  881 
cases  with  171  fatalities,  are  as  follows: 

Sepsis  and  pyfemia 46,         26.8  per  cent. 

Peritonitis 37,         21 .6 

Collapse  and  heart  failure 32,         18.7       " 

Pulmonary  affections 21,         12  " 

Miscellaneous  causes 35,         20  " 

(Areliiv  fur  klin.  Chir.,  1900,  S.  309.) 

In  the  collection  of  Finet  there  were  76  deaths  due  to  the  following 
causes: 

Peritonitis 24,  31      per  cent. 

Septic£eraia 13,  17           " 

Pyaemia 2,  2.6       " 

Collapse 16,  21 

Gangrene  of  the  rectum 3,  3.9       " 

Pulmonary  complications 4,  5           " 

Haemorrhage 1,  1           " 

Diarrhoea 1,  1           " 

Iodoform  poisoning 1,  1           " 

Miscellaneous  causes 11,  14          " 

Quenu  and  Hartmann  say,  in  discussing  the  latter  figures,  that  if 
the  cases  of  peritonitis,  septicaemia,  gangrene,  and  pyemia  were  all 
united  under  one  head  of  sepsis,  we  would  have  a  mortality  from  this 
cause  of  over  60  per  cent,  and  even  this  is  below  the  reality.  They 
believe  that  all  cases  dying  within  the  first  thirty-six  or  forty-eight 
hours  and  diagnosed  collapse,  succumb  to  a  form  of  acute  sepsis  charac- 
terized by  low  or  subnormal  temperature,  quick  pulse,  and  suppression 
of  urine.  The  pulmonary  complications,  either  early  or  late,  they  claim 
are  due  to  the  same  cause;  and  on  the  whole  they  do  not  consider  it 
an  exaggeration  to  state  that  full  80  per  cent  of  the  mortality  from 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA        789 

operations  of  this  kind  are  the  result  of  some  form  of  sepsis  (Chirur. 
dii  rectum,  t.  ii,  p.  132).  The  author  is  entirely  in  accord  with  the 
views  of  these  eminent  surgeons;  indeed,  he  helieves  that  if  gangrene 
and  chronic  exhaustive  suppuration  be  added  to  the  category  of  sepsis, 
the  deaths  from  this  cause  would  amount  to  more  than  90  per  cent  of 
all  fatalities.  The  high  mortality  from  this  operation,  therefore,  is  due, 
not  to  the  magnitude  or  difficulty  of  the  procedure,  but  to  infection; 
we  have  not  arrived  at  that  stage  of  perfection  in  aseptic  technique  in 
this  variety  of  operations  that  we  have  in  many  others.  Carelessness 
in  detail  is  the  cause  of  much  of  this.  The  author  has  seen  various 
operators  do  extirpation  of  the  rectum,  and  time  after  time  during  the 
procedure  introduce  a  finger  into  the  gut  and  back  into  the  wound. 
It  is  absolutely  impossible  to  sterilize  the  intestinal  canal,  however  much 
care  is  taken,  and  if  this  practice  is  followed  by  many  surgeons,  it  will 
account  for  the  high  percentage  of  infections  and  the  great  mortality 
due  to  this  cause.  Much  of  this  is  avoidable.  Another  cause  of  high 
mortality  is  too  great  boldness  in  operating,  itndertaking  impossible 
cases.  It  is  a  question  how  far  this  cause  can  be  avoided.  Had  the 
author  refused  to  operate  in  2  such  cases  instead  of  jdelding  to  the 
importimities  of  the  patients,  the  mortality  in  his  series  of  cases  would 
be  12.5  per  cent;  but  if  the  patient  demands  it,  has  the  surgeon  a  right 
to  refuse  him  even  one  chance  in  a  thousand  for  his  life? 

While  extirpation  offers  a  much  smaller  probability  of  permanent 
cure  than  could  be  wished,  and  while  even  this  prospect  must  be  pur- 
chased at  the  price  of  one  chance  in  five  of  death,  it  still  offers  to  these 
unfortunate  suff'erers  relief  from  pain,  a  surcease  from  the  inveterate 
and  uncontrollable  diarrhoea,  a  cessation  for  considerable  periods,  at 
least,  of  the  excessive  discharges  and  frequent  hemorrhages,  and,  finally, 
a  hope,  though  feeble  and  faint  yet  far-reaching  in  its  influence,  of 
eventual  cure.  In  contradistinction  to  this,  what  has  the  palliative 
treatment  to  offer?  A  relief  from  pain  through  the  administration  of 
opiates  or  through  diversion  of  the  fa?cal  current,  either  in  the  form 
of  an  artificial  anus  or  through  entero-anastomosis.  There  is  absoltitely 
no  proof  that  either  of  the  latter  procedures  retards  the  extension  of 
the  disease  in  continuity  or  by  metastasis.  In  certain  instances  they 
relieve  the  pain  to  some  extent,  but  never  to  the  same  degree  as  extirpa- 
tion; they  undoubtedly  improve  the  digestive  functions  and  control  the 
diarrhcea,  which  is  annoying  and  exhausting;  they  reduce  septic  ab- 
sorption, and  consequently  prolong  life,  and  the  mortality  from  the 
operations  is  very  small.  They  offer,  however,  no  hope  beyond  a  lethal 
end  in  about  one  and  a  half  years.  The  modern  methods  of  performing 
colostomy  make  it  a  less  disagreeable  and  disgusting  feature  than  for- 
merly, as  will  be  described  later  on;  but  the  very  fact  that  the  fsecal 


790  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

movements  must  be  discharged  from  an  abnormal  aperture;  that  band- 
ages, trusses,  or  faecal  receptacles  must  be  worn  at  all  times  in  order  to 
prevent  accidental  fsecal  escape  and  mortification  to  the  patient,  keeps 
constantly  before  his  mind  the  fact  that  the  fatal  malady  still  exists, 
and  it  has  therefore  a  depressing  rather  than  an  encouraging  influence. 
In  short,  these  methods  offer  the  patient  and  his  friends  absolutely  no 
hope  of  cure,  only  a  relief  from  some  of  the  disagreeable  symptoms,  and 
then  resign  him  to  fate  and  the  euthanasia  of  opium  until  the  end 
appears. 

Indications  and  Contraindications  to  Different  Methods  of  Treatment. 
— It  is  clear  from  the  foregoing  paragraphs  that  the  author  is  in  favor 
of  extirpation  in  all  suitable  cases  of  carcinoma  of  the  anus,  rectum,  and 
sigmoid.  It  is  believed,  however,  that  a  more  careful  discrimination 
should  be  made  in  the  cases  selected;  to  this  end  the  reader  is  invited 
to  a  closer  study  of  the  indications  for  radical  treatment. 

Indications  for  Extirpation. — In  a  general  way  it  may  be  said  that 
extirpation  is  indicated  when  the  growth  is  movable  and  does  not  in- 
volve other  organs;  when  no  metastasis  or  ganglionic  extension  has 
occurred;  when  the  patient's  physical  condition  is  such  that  he  is  able 
to  withstand  the  shock  of  operation,  and  when  marked  cachexia  is 
not  present. 

It  is  contraindicated  when  other  pelvic  organs  or  the  bony  frame 
are  involved;  whenever  the  disease  has  extended  to  the  remote  lymphat- 
ics; when  there  is  positive  indication  of  the  generalization  of  cancer 
exemplified  in  nodules  upon  the  liver,  in  the  skin,  or  in  other  remote 
organs;  in  low  physical  conditions  with  rapid  pulse,  cachexia,  and 
periodical  elevations  of  temperature.  It  is  specially  contraindicated 
in  cases  with  marked  digestive  disturbances.  Recovery  after  these  opera- 
tions depends  largely  upon  the  ability  to  assimilate  food  and  resist  in- 
fection, and  if  the  digestive  functions  are  deficient  these  indications 
can  not  be  met. 

It  is  not  always  wise,  however,  to  adhere  too  closely  to  these  indica- 
tions. The  rectum  may  be  adherent  to  the  prostate,  bladder,  or  uterus 
through  simple  inflammatory  processes,  and  the  latter  organs  may  be 
absolutely  free  from  malignant  disease;  the  liver  may  be  enlarged  from 
congestion  or  other  causes  in  cases  with  carcinoma  of  the  rectum,  and 
yet  not  be  involved  in  the  malignant  process;  the  growth  may  be  firmly 
bound  down  to  the  sacrum  by  inflammatory  bands  without  the  perios- 
teum partaking  of  the  malignancy.  On  this  account,  Quenu,  Czerny, 
and  Bardenheuer  (Quenu  and  Hartmann,  op.  cit.,  vol.  ii,  p.  237)  do  not 
any  longer  hesitate,  when  it  is  only  a  question  of  adhesion  to  the  prostate 
and  seminal  vesicles,  to  extirpate  the  growth  with  parts  of  these  organs, 
always  respecting  the  urinary  tract.    Kelsey  (Surg,  of  Eect.  and  Pelvis, 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA        791 

1897,  p.  287),  however,  says  he  has  ceased  attempting  even  these  cases. 
The  author  is  in  accord  with  the  French  surgeons  on  this  poiat,  and 
would  not  hesitate  to  operate  on  account  of  such  adhesions.  Frequently 
it  is  impossible  to  determine  the  ganglionic  extension  through  rectal 
examination  and  abdominal  palpation.  One  of  the  many  advantages 
of  preliminary  colotomy  consists  in  the  opportunity  of  closely  examining 
the  parts  and  determining  whether  or  not  this  has  occurred.  It  also 
enables  one  to  examine  the  bladder  and  uterus  so  thoroughly  that  it  is 
possible  to  determine  whether  the  malignant  process  has  extended  to 
these  organs,  or  whether  the  adhesions  are  simply  of  an  inflammatory 
nature  (Schwartz,  Eevue  clin.  et  de  therap.,  1890,  No.  42;  Adamski, 
Th.  de  Paris,  1899,  Ko.  97;  Quenu  and  Hartmann,  op.  cit.,  vol.  ii,  p. 
237).  When  the  latter  is  the  case,  extirpation  may  be  attempted  with 
fairly  good  prospects  of  success. 

The  type  of  the  tumor  should  always  be  considered  in  determining 
for  or  against  operation.  The  prognosis  is  much  more  favorable  in  scir- 
rhus  and  adeno-carcinoma  than  in  the  medullary  and  squamous  varieties. 
In  the  latter,  ganglionic  and  metastatic  extension  occur  at  an  earlier 
period  than  in  the  former,  and  recurrences  are  therefore  more  frequent. 

With  regard  to  involvement  of  the  vaginal  wall,  it  would  seem  that 
this  should  not  form  a  very  strong  contraindication  to  extirpation  of 
carcinoma  of  the  rectum.  As  a  matter  of  fact,  however,  experience 
teaches  us  that  in  the  majority  of  such  cases  generalization  has  already 
occurred,  or  it  comes  on  early  after  operation.  This  complication  should 
therefore  be  considered  a  very  serious  one. 

The  rule  formulated  by  Van  Buren  that  no  cancer  of  the  rectum 
should  be  removed,  the  upper  limits  of  which  could  not  be  made  out 
by  digital  examination,  is  no  longer  followed.  The  tolerance  of  the 
peritonseum  to  invasion  under  ordinary  aseptic  precautions  renders  any 
limitations  with  regard  to  the  height  of  the  tumor  no  longer  necessary. 
Those  low  down  may  be  removed  by  perineal  methods,  those  in  the 
ampullary  or  upper  portion  of  the  rectum  by  the  sacral  route,  and  those 
high  up  in  the  rectum  or  sigmoid  by  the  abdominal  or  combined  methods. 
The  area  involved  by  the  tumor  may  be  a  contraindication,  from  the  fact 
that  the  more  extensive  the  growth  the  more  likely  is  there  to  be  in- 
volvement of  the  neighboring  organs,  ganglionic  extension,  or  general- 
ization of  the  disease.  Long  sections — 20,  25,  and  36  centimeters — of 
the  rectum  and  sigmoid  have  been  removed,  but  death  or  early  recur- 
rence has  almost  invariably  resulted.  The  author  has  successfully  re- 
moved 12  inches  of  these  organs,  and  the  patient  still  lives  twenty-six 
months  after  the  operation,  but  such  results  can  not  be  expected  often. 

Two  other  things  need  to  be  considered  in  determining  for  or  against 
extirpation  of  carcinoma  of  the  rectum:  the  desire  of  the  patient  and 


792  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

the  preparation  of  the  surgeon.  If  it  is  one's  ambition  to  obtain  a  record 
for  low  mortality  in  these  operations;,  he  will  adhere  closely  to  the  lines 
laid  down  above,  and  decline  to  operate  on  any  complicated  cases.  The 
patient,  however,  has  certain  rights  which  should  be  respected.  He  is 
entitled  to  know  that  he  is  afflicted  with  a  fatal  malady  and  exactly  what 
chances  he  has  for  a  radical  cure  of  the  same.  With  this  knowledge  he 
should  have  the  privilege  of  deciding  for  himself  whether  he  will  take 
the  one  chance  of  life  in  comfort,  and  failing  put  an  end  to  all  his  suffer- 
ings, or  adopt  a  waiting  course,  obtaining  what  relief  he  can  from  pallia- 
tive methods.  It  is  the  author's  firm  conviction  that  no  surgeon  is 
justified  to  refuse  the  one  chance  to  be  cured  of  this  disease  even  in  the 
most  desperate  cases,  if  the  patient  elects  to  take  the  responsibility  of  a 
fatal  termination.  Such  action  will  not  conduce  to  a  lowered  mortality 
in  this  operation,  but  in  the  majority  of  cases  death  is  preferable  to  life 
with  such  a  malady  ever  slowly  and  painfully  progressing  toward  the 
end.  One  might  just  as  well  say  that  a  man  has  no  right  to  jump  from 
a  burning  building  and  thus  take  the  one  chance  of  living,  even  though 
a  cripple,  as  to  deny  these  patients  the  right  to  choose  for  themselves. 
It  is  the  author's  practice  in  such  cases  to  present  the  facts  and  probabil- 
ities to  the  patient  and  his  friends,  and  leave  them  to  decide  whether 
they  will  choose  a  palliative  or  radical  course  of  treatment.  In  three 
instances  he  has  been  persuaded  to  operate  where  it  was  his  positive 
conviction  that  no  possible  good  could  be  achieved;  two  of  these  patients 
died  shortly  after  the  operation,  the  third  and  most  desperate  one  was 
restored  to  health,  and  when  last  heard  from,  over  three  years  after  the 
operation,  was  supporting  his  family  in  spite  of  the  unfavorable  prog- 
nosis. Thus  the  end  was  hastened  in  two  hopeless  cases  and  a  useful  life 
was  rescued  in  the  third.    This  case  is  worthy  of  particular  mention: 

Amputation  of  the  Rectum,  including  the  Entire  Prostate  and  Parts  of  the  Urethra 
and  Bladder. — R.  G.,  thirty-five,  entered  the  Polyclinic  Hospital,  January  9,  1899. 
He  gave  an  indefinite  history  of  constipation,  haemorrhages,  gradually  increasing 
pain,  and  protrusion  from  the  rectum.  The  symptoms  had  existed  for  over  one 
year,  during  which  time  he  had  been  treated  for  piles  almost  constantly.  From 
the  anus  there  protruded  a  wart-like  mass,  and  as  far  up  as  the  finger  could  be 
introduced  the  rectal  caliber  was  filled  by  similar  neoplasms.  The  patient  was  in 
a  most  emaciated  condition;  his  pulse  was  140,  temperature  subnormal,  and  he 
required  thirty-six  grains  of  morphine  per  day  to  be  made  comfortable. 

January  15th. — Left  inguinal  colotomy  after  Maydl-Reclus  method,  sphincter 
dilated,  and  protruding  epithelial  mass  clamped  oflf.  Examination  of  the  pelvis 
througli  the  abdominal  opening  demonstrated  involvement  of  the  lower  posterior 
wall  of  the  bladder  and  prostate  in  the  neoplasm.  The  prevertebral  glands  were 
not  involved  apparently,  and  the  liver  was  perfectly  smooth.  The  patient  improved 
greatly  follovring  the  operation ;  and,  after  the  bowel  was  opened,  he  was  compar- 
atively comfortable.     He  was  advised  against  having  any  further  operation  done. 

February  7th. — Yielding  to  the  patient's  importunities,  an  attempt  was  made  to 


MALIGXAXT   XEOPLASMS-CARCIXOMA  A^'D   SARCOMA         793 

extirpate  the  carcinoma.  Sis  inches  of  the  rectum.  IJ  inch  of  the  urethra,  the 
entire  prostate,  and  nearly  1  square  inch  of  the  posterior  -^-all  of  the  bladder  "vrere 
removed  in  doing  this.  The  patient  became  very  weak  during  the  operation,  and 
it  was  necessary  to  shorten  the  jDrocedure  as  much  as  possible.  It  was  therefore 
impossible  to  accurately  close  the  bladder  wound  and  make  any  attempt  at  restora- 
tion of  the  urethra  at  this  time.     Length  of  operation,  forty-five  minutes. 

February  lith. — The  patient  recuperated  rapidly,  and  gained  strength  every 
day. 

February  21st. — An  attempt  was  made  to  close  the  wound  in  the  bkdder  and 
restore  the  urethra  by  freshening  the  edges  and  drawing  the  parts  together.  It 
■was  impossible  to  bring  the  ends  of  the  urethra  together,  therefore  a  drainage- 
tube  was  passed  along  the  perineal  wound  into  the  bladder,  and  around  this  the 
neck  of  the  latter  organ  was  sutured.  Comparatively  good  union  was  obtained  in 
this,  and  the  patient  was  left  with  a  perineal  urethra.  After  the  parts  healed,  the 
bladder  could  retain  about  2  ounces  of  urine,  but  no  more,  and  it  was  found 
necessary  for  the  patient  to  wear  a  perineal  urinal. 

The  upper  end  of  the  rectum,  where  it  was  cut  off,  was  not  closed  or  sutured 
in  any  way,  but  simply  packed  with  gauze.  At  the  time  the  patient  left  the  hos- 
pital, March  18th,  there  was  only  a  slight  fistulous  tract  leading  up  from  the  site 
of  the  anus  to  this  point.  The  patient  entirely  relinquished  his  morphine  habit 
within  three  weeks,  and  was  on  his  feet  walking  about  the  ward  in  two  weeks 
after  the  second  operation. 

The  results  in  such  eases  as  this  render  us  bolder  to  undertake  appar- 
ently impossible  operations.  Such  attempts  are  justifiable  upon  the  in- 
sistence of  the  patient,  but  they  should  never  be  urged  by  the  surgeon. 

The  capability  and  preparation  of  the  surgeon  are  of  the  utmost  im- 
portance in  determining  upon  this  operation.  While  asepsis  is  the  chief 
feature  in  the  technique,  the  time  occupied  and  the  control  of  haemor- 
rhage are  major  considerations.  Every  minute  and  every  drop  of  blood 
saved  in  such  a  procedure  add  to  the  patient's  chances  of  life.  Absolute 
familiarity  with  the  anatomy  of  the  parts  and  every  step  of  the  operation 
are  necessary  to  success.  Blind  groping  in  an  unknown  field,  feeling 
one's  way  step  by  step,  results  not  only  in  useless  loss  of  time  and  blood, 
but  frequently  in  injury  of  the  adjacent  organs,  such  as  the  urethra, 
bladder,  and  ureters.  The  surgeon  who  proposes  to  do  this  operation 
should  certainly  practise  it  on  the  cadaver  many  times  before  he  rmder- 
takes  it  on  a  living  subject. 

Indications  for  Palliative  Treatment. — These  methods  of  treatment 
are  indicated  when  from  one  cause  or  another  extirpation  is  not  advis- 
able, and  as  preliminary  preparations  for  the  latter  operation.  THiere 
great  weakness  and  excessive  digestive  disturbances  exist,  it  should  be 
employed  with  the  view  of  improving  the  patient's  condition  suflaciently 
to  justifv  extirpation.  It  should  always  be  employed  in  some  form  for 
eight  to  fifteen  days  before  extirpation,  and  it  will  therefore  be  de- 
scribed first. 


794  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

Palliative  Treatment. — This  consists  in  diet,  antiseptic  and  astrin- 
gent irrigation,  curettage,  cauterization,  colotomy,  entero-anastomosis, 
and  the  free  use  of  opium.  The  chief  element  in  the  prolongation 
of  life  in  inoperable  cases  is  the  ability  of  the  patient  to  resist  in- 
fection. Wherever  the  digestive  functions  remain  good  and  the  patient 
is  properly  fed,  this  resistance  is  maintained  and  the  constitutional 
effects  of  the  disease  are  retarded.  Forced  feeding  with  predigested 
food,  milk,  egg  albumen,  meat  extracts,  and  small  quantities  of  well- 
cooked  cereals  are  always  indicated. 

Sweets,  uncooked  starches,  fibrous  vegetables,  and  articles  contain- 
ing much  detritus  should  be  avoided.  Milk  diet  alone  has  not  been 
found  advisable  in  these  cases,  but  associated  with  other  aliment  it  is  of 
the  greatest  benefit. 

Irrigation. — Irrigation  of  the  affected  part  is  indicated,  especially  in 
those  cases  in  which  there  is  much  discharge  associated  with  a  frequent 
diarrhoea,  or  in  which  there  is  a  tendency  to  hard,  lumpy  stools.  The 
substances  which  have  been  found  most  satisfactory  for  this  purpose  are 
solutions  of  boric  acid  o  per  cent,  hydrastis  1  per  cent,  krameria  aq.  ext. 
5  per  cent,  bichloride  of  mercury  1  to  10,000,  and  carbolic  acid  1  to  100. 

The  method  of  employing  irrigation  in  these  cases  depends  upon 
the  site  of  the  growth.  In  those  cases  low  down  about  the  margin  of 
the  anus,  the  solutions  may  be  sprayed  upon  the  parts,  a  certain  portion 
being  carried  up  into  the  rectum  simply  to  act  as  an  enema  in  unloading 
the  bowels.  Where  the  tumor  is  in  the  ampulla  of  the  rectum  an 
ordinary  rectal  irrigator  (Fig.  83)  should  be  used  with  the  patient 
lying  upon  the  side.  Where  the  growth  is  higher  up  at  the  junction 
of  the  rectum  with  the  sigmoid  or  in  the  latter  organ,  the  irrigation 
should  be  carried  on  by  placing  the  patient  in  the  knee-chest  posture, 
allowing  the  fluid  to  run  in  slowly  from  a  fountain  syringe  so  that  it  will 
find  its  way  above  the  affected  area  and  thus  wash  out  whatever  mucus, 
pus,  and  fax-al  material  have  accumulated  above  or  below  the  growth. 
In  cases  which  are  too  weak  to  assume  this  position  long  enough  for 
the  fluid  to  pass  in  slowly,  a  small  Wales  bougie,  Nos.  3  or  4,  which 
is  practically  a  soft-rubber  catheter  open  at  the  end,  may  be  gently 
introduced  by  an  expert  nurse,  and  thus  the  fluid  can  be  carried  above 
the  growth.  Of  course  it  is  always  possible  that  this  tube  may  bend 
upon  itself,  and,  as  said  before,  there  is  a  certain  amount  of  danger  in 
introducing  such  instruments,  but  with  a  soft  bougie  of  small  size  this 
is  not  very  great. 

The  amount  of  good  which  can  be  accomplished  by  this  dietary 
and  antiseptic  treatment  does  not  seem  to  be  appreciated  by  most 
writers  upon  this  subject.  The  aiithor  has  seen  a  number  of  inoperable 
cases  not  only  hold  their  own,  but  gain  flesh  and  strength  under  it. 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA        795 

In  several  cases  he  has  seriously  doubted  his  own  diagnosis  on  account 
of  the  remarkable  improvement.  In  some  cases  in  which  the  local 
condition  indicates  operative  interference^  the  patient's  general  con- 
dition contraindicates  it.  In  these  instances  one  may  occasionally  im- 
prove the  general  condition  to  such  an  extent  that  extirpation  will 
become  feasible  where  it  was  not  so  at  the  first  examination. 

Drugs. — As  to  therapeutic  remedies,  little  can  be  accomplished  except 
by  the  artificial  aids  to  digestion,  tonics  and  stimulants  to  circulation, 
and  such  remedies  as  prevent  fermentation  in  the  intestinal  tract.  The 
author  is  opposed  to  the  administration  of  opium  by  the  mouth,  as  it 
interferes  seriously  with  the  digestion,  produces  hard,  lumpy  stools 
which  are  dangerous  in  this  disease,  and  it  accomplishes  nothing  in 
the  control  of  the  irritative  diarrhoea  that  can  not  be  accomplished  by 
irrigations  and  proper  diet.  For  the  relief  of  pain,  hypodermics  of 
morphine  are  admissible,  but  they  should  not  be  too  freely  used  until 
the  disease  has  progressed  to  its  latest  stages.  When  the  hopeless,  bed- 
ridden stage  has  been  reached,  then  the  unlimited  administration  of  the 
drug  should  be  employed  to  relieve  suffering  and  quiet  mental  anxiety. 

Curettage. — Where  there  are  no  great  septic  symptoms,  but  the  pa- 
tient's life  is  drained  by  frequent  and  exhausting  hemorrhages  from 
large,  soft,  pulpy,  inoperable  tumors  attached  to  the  posterior  wall, 
we  may  have  recourse  to  curettage  for  the  relief  of  this  condition.  If 
the  growth  involves  the  anterior  or  lateral  wall  of  the  gut,  this  opera- 
tion is  not  safe,  as  one  may  very  easily  penetrate  the  peritongeum;  at 
the  same  time,  in  expert  and  careful  hands,  the  anterior  cancerous 
excrescences  may  be  twisted  or  crushed  off  with  pressure  forceps,  and 
scraped  out  posteriorly  so  as  to  greatly  increase  the  caliber  of  the  gut 
and  check  for  considerable  periods  the  dangerous  bleeding.  Where  the 
hgemorrhages  are  not  accompanied  with  much  pain,  the  author  believes 
this  method  will  give  quite  as  much  relief  as  an  artificial  anus,  and  it 
will  render  the  after-care  of  the  patient  less  burdensome  to  the  attend- 
ants. After  the  curettage,  hot  or  cold  irrigation  should  be  employed 
to  check  the  bleeding,  and  afterward  a  drainage-tube  should  be  intro- 
duced into  the  rectum  and  firmly  packed  around  with  sterilized  gauze 
infiltrated  with  suprarenal  extract  or  dried  persulphate  of  iron.  It  is 
not  safe  to  pack  such  large  cavities  with  10-per-cent  iodoform  gauze 
on  account  of  the  toxic  effect  of  this  drug. 

Cauterization. — In  the  same  class  of  cases  as  those  just  mentioned, 
one  may  employ  the  actual  cautery  to  control  the  bleeding.  It  is  slower 
in  its  action  than  curettage,  and  more  likely  to  result  in  peritonitis 
through  heat  radiation. 

Where  the  growth  is  Ioav  down  and  the  excrescences  are  of  a  papil- 
lomatous or  polypoid  nature,  they  may  be  grasped  with  a  h^emorrhoidal 


796  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

clamp,  crushed  off  and  cauterized,  thus  accomplishing  the  control  of 
haemorrhage  and  widening  of  the  rectal  caliber.  The  author  is  opposed 
to  the  use  of  chemical  cauteries  in  such  cases,  and  believes  the  Paquelin 
knife  is  the  only  agent  which  should  be  emploj'ed  if  this  method  of 
treatment  is  adopted. 

Colostomy  in  Malignant  Tumors  of  the  Rectum. — The  opinions  and 
experiences  of  surgeons  vary  greatly  with  regard  to  the  emploj-ment  of 
colostomy  in  cancer  of  the  rectum  and  sigmoid.  Some  believe  that  it 
is  never  justifiable,  others  that  it  is  the  only  justifiable  operation  which 
affords  these  unfortunate  sufferers  any  relief.  It  is  employed  to  avoid 
obstruction,  prevent  hsemorrhage,  control  diarrhoea,  check  sepsis,  and 
as  a  preliminary  operation  to  extirpation.  Some  surgeons,  notably 
Allingham  and  Kelsey,  claim  to  accomplish  all  these  ends  by  this 
procedure;  in  the  hands  of  others  the  operation  has  not  been  so  satis- 
factory. 

Where  the  growth  is  low  down  and  involves  the  sphincter,  an  artificial 
anus  will  prevent  the  intense  suffering  which  follows  every  stool.  In 
some  cases  it  controls  the  diarrhoeal  movement,  but  in  others  it  fails 
to  relieve  the  unceasing  desire  to  defecate;  in  these  cases  small  mucous 
and  bloody  passages  continue  from  the  anus  after  the  colostomy  has 
been  done.  Usually  it  checks  the  septic  manifestations,  although  this 
is  not  invariably  the  case.  It  undoubtedly  improves  the  digestive  func- 
tions, and  for  the  first  three  or  four  months  after  its  performance  the 
patient  gains  in  strength  and  flesh.  In  the  control  of  haemorrhage  it 
has  no  distinct  advantages  over  curettage,  dietary  regime,  and  rectal 
irrigation.  It  may  check  the  inflammatory  processes  around  the  can- 
cer, but  there  is  no  reason  to  suppose  that  it  inhibits  the  growth  of  the 
neoplasm.  That  it  prevents  intestinal  obstruction  can  not  be  denied, 
but,  as  has  been  stated  alread}',  this  is  a  very  rare  accident  in  carcinoma 
of  the  rectum.  In  the  sigmoid,  where  scirrhous  cancer  is  somewhat 
more  frequently  observed,  obstruction  is  more  likely  to  occur,  but  in 
these  cases  the  condition  of  affairs  is  usually  recognized  at  a  time 
when  extirpation  is  altogether  feasible,  and  therefore  colostomy  is  not 
called  for. 

The  writer  is  not  among  those  who  hold  that  an  artificial  anus  is 
the  most  disgusting  and  distressing  condition  to  which  a  patient  can 
be  subjected.  He  believes  that  in  many  diseases,  such  as  chronic  ulcera- 
tion of  the  rectum,  syphilitic  stricture,  multiple  polypi,  complicated 
fistulas,  etc.^  it  is  one  of  our  most  useful  aids.  The  modern  methods 
of  colostomy  have  rendered  the  faecal  control  so  complete  that  many 
of  the  most  disgusting  features  have  been  obliterated.  At  the  same  time 
it  does  not  appear  indicated  in  carcinoma  of  the  rectum  except  in  the 
rarest  instances.    The  writer  has  never  seen  a  case  of  obstruction  from 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA 


(97 


carcinoma  of  the  rectum,  and  in  20  colotomies  for  this  disease  he  has 
never  seen  a  patient  live  longer  than  one  year  after  the  operation. 
It  has  always  been  necessary  to  resort  to  morphine  almost  as  freely 
as  before  the  colotomy,  and  in  most  of  the  cases  periodical  hemorrhages 
have  occurred  long  after  the  faecal  current  had  been  turned  aside.  He 
therefore  employs  it  only  in  inoperable  cases  where  the  sphincter  is 
involved.  As  a  preliminary  to  extirpation  of  the  rectum,  colostomy 
can  not  be  too  highly  praised.  The  operation  is  of  such  great  impor- 
tance in  rectal  surgery,  and  applicable  to  such  various  conditions,  that 
it  has  been  deemed  advisable  to  devote  a  special  chapter  to  its  con- 
sideration. 

E titer o-anastomosis. — Under  the  same  conditions  as  those  stated  for 
colostomy,  one  may  employ  entero-anastomosis  in  cases  where  the  tumor 
is  high  up  in  the  rectum  or  in  the  sigmoid  flexure.  Where  there  is 
sufficient  healthy  gut  below  the  growth  to  admit  of  a  union  between 
the  upper  loops  of  the  sigmoid,  the  csecum,  or  the  ileum  with  the 
rectum,  the  portion  of  the  intestine  involved  in  the  neoplasm  may  be 
thus    eliminated    from    the 

fsecal  tract  and  all  the  ad-  ^..^H^P-^^^.-r-^wir*-- 

vantages  of  an  artificial 
anus  obtained  without  any 
of  its  disgusting  features. 

The  operation  possesses 
one  great  recommendation, 
in  that  it  produces  no  con- 
stant reminder  of  the  pa- 
tient's actual  condition  in 
the  shape  of  an  abnormally 
placed  anus.  The  fsecal 
current  apparently  passes 
through  the  normal  chan- 
nels, it  produces  no  irri- 
tation of  the  neoplasm,  and 
is  thus  far  more  satisfac- 
tory than  the  permanent 
artificial  anus.  It  is  a  more 
serious  and  difficult  opera- 
tion to  perform  than  colosto- 
my, but  the  death-rate  from 
it  is  not  particularly  high. 

This  operation,  first  performed  by  Wallh  (St.  Petersburg  med.  Woch., 
February  12,  1889),  is  chiefly  employed  for  inoperable  tumors  of  the 
large  intestine  above  the  sigmoid  flexure.    We  are  able  to  find  but  three 


r 


\- 


Fig.  257. — Lateral  Entero-anastomosis. 


ros 


THE   ANUS,   RECTUM,   AND   PELVIC   COLON 


Fig.  258. —  hi...-.--  mi  Complete 
Elimixatiux  of  the  F.ecal  Clrrejtt  from 
THE  Diseased  Area. 


instances  in  which  it  has  been  employed  in  neoplasms  of  the  sigmoid 
flexure  (Stimson's,  Darling's,  and  the  author's).  It  consists  in  anas- 
tomosing a  healthy  portion  of  the  intestine  above  the  growth  with  one 
below  it.  There  are  two  methods  emplo3-ed  in  its  performance.  One 
consists  in  a  lateral  anastomosis  of  two  segments,  eitber  by  the  use  of 

Senn's  bone  plates  or  the 
Murphy  button  (Fig.  25T). 
By  this  method  the  portion 
of  the  intestine  involved  in 
the  neoplasm  retains  its 
connection  with  the  rest  of 
the  intestine,  and  a  certain 
amount  of  the  intestinal 
^  ,  contents  escapes  into  it   or 

■L  /  ^     probably    through    it.      By 

vxl  ^  '""^^^fUttf/^?*^^''    .     f      the  second  method  the  por- 

tion involved  is  entirely  ex- 
cluded from  the  faecal  cur- 
rent. The  intestine  is  cut 
through  above  the  growth 
and  below  it  under  proper 
aseptic  precautions.  The  two  ends  of  the  diseased  portion  are  then 
invaginated  and  closed  by  Lembert  sutures.  The  healthy  segments 
above  and  below  the  growth  are  then  united  by  end-to-end  suturing  or 
a  ^Murphy  button,  thus  establishing  a  tract  for  the  fscal  current  which 
has  no  connection  whatever  with  that  portion  of  the  intestine  involved 
in  the  growth  (Fig.  258).  The  section  thus  eliminated  from  the  intes- 
tinal tract  atrophies  and  appears  to  occasion  no  inconvenience,  but  the 
neoplasm  continues  to  grow,  and  eventually  ends  in  death  through 
metastasis. 

In  the  authors  case  the  sigmoid  flexure,  the  ascending  transverse 
and  descending  colon,  and  about  18  inches  of  the  ileum  were  eliminated 
from  the  intestinal  tract  on  account  of  a  tumor  involving  the  sigmoid 
and  ileum.  The  upper  end  of  the  rectum  was  then  invaginated  and 
closed,  a  longitudinal  incision  was  made  in  its  anterior  wall,  and  the 
upper  end  of  the  ileum  was  then  dragged  down  through  this  slit,  after 
the  manner  suggested  by  Kelly  (Fig.  259).  The  new  faecal  tract  was 
perfectly  established,  and  the  patient's  bowels  moved  regularly  and 
without  pain  until  his  death,  which  occurred  from  rupture  of  the 
left  iliac  artery,  which  was  involved  in  the  disease,  45  days  after  the 
operation. 

While  the  results  from  this  procedure  are  comparatively  satisfactory 
in  tumors  of  the  colon  above  the  lower  loops  of  the  sigmoid,  it  is  rarely 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA        799 


applicable  to  tumors  of  the  rectum  and  pelvic  colon.  In  the  case  re- 
ferred to^  the  ileum  was  involved  with  the  sigmoid  in  the  neoplasm. 
This  would  have  necessitated  an  artificial  anus  being  made  in  the  ileum 
in  order  for  it  to  be  of  any  benefit,  and  it  is  well  known  that  ani  made 
in  this  portion  of  the  intestine  are  not  only  distressing  to  the  patient 
on  account  of  the  fluid  condition  of  the  faeces  at  this  point,  but  also 
followed  by  rapid  exhaustion  through  the  constant  diarrhoea  which  they 
occasion.  In  such  an  instance^  therefore,  where  the  tumor  can  not 
be  removed,  this  operation  is  called  for;  but  complications  like  this  in 
which  the  sigmoid,  the  small  intestine,  and  the  iliac  vessels  were  all 
involved,  are  exceedingly  rare. 

In  addition  to  these  forms  of  treatment,  one  should  not  forget  to 
mention  the  interesting  experiments  which  are  now  being  made  in  the 
treatment  of  cancer  by  the  X-ray  and  phototherapy.  Most  encouraging 
results  have  been  obtained  by  the  use  of  these  methods  in  carcinomas, 
especially  of  the  epithelial 
type,  in  other  portions  of 
the  body,  and  it  is  not  un- 
reasonable to  suppose  that 
the  same  can  be  obtained 
at  least  in  the  lower  por- 
tion of  the  rectum.  Thus 
far  the  author  has  had  no 
experience  in  their  use,  and 
must  therefore  refer  his 
readers  to  Williams's  ex- 
cellent work  upon  this  sub- 
ject and  the  extensive 
journal  literature  of  the 
day.  Subjecting  the  meth- 
ods to  the  same  test  which 
we  apply  to  surgical  pro- 
cedures— viz.,  three  or  four 
years'  freedom  from  recur- 
rence —  it  has  not  been 
shown  that  they  have  ef- 
fected a  single  permanent 
cure;  but  the  period  during 
which  these  methods  have 
been  employed  is  entirely 

too  short  for  the  practical  application  of  such  a  test.  We  can  only 
hope  that  they  will  prove  as  effectual  as  some  of  their  advocates 
predict. 


Fig.  259. — Anastomosis  of  the  Ileum  ■with  the  Eec- 
TUM  FOR  Carcinoma  of  the  Sigmoid  and  Ileum. 


800  THE  ANUS,  RECTUM,  AND   PELVIC   COLON 

SARCOMA 

These  occur  under  the  two  general  types  of  melanotic  and  non- 
melanotic  sarcomas;  the  latter  are  much  more  rare  in  the  rectum  than 
the  former;  the  collected  cases  include  29  of  the  melanotic  and  14  of 
the  non-melanotic  sarcomas. 

This  pigmentation  or  melanosis  is  not  the  all-important  element  in 
these  tumors,  for  it  may  complicate  any  variety  of  sarcoma,  and  has  also 
been  seen  to  occur  in  carcinoma  of  the  rectum  (Eoecke,  Inaug.  Dissert., 
Freiburg,  1895).  This  latter  is  exceedingly  rare;  there  is  not  another 
instance  recorded  of  such  infiltration  of  carcinoma  of  the  rectum,  and 
were  it  not  for  the  very  minute  report  of  Roecke,  one  would  feel  in- 
clined to  doubt  the  accuracy  of  the  histological  investigation.  The 
only  plausible  reason  for  its  comparatively  frequent  occurrence  in  sar- 
comas is  the  thinness  of  the  blood-vessel  walls^  and  this  explanation  is 
only  partially  satisfactory. 

Form. — Sarcomas  occur  in  the  rectum  as  irregular  deposits  beneath 
the  mucous  membrane.  Their  shapes  are  round,  elliptical,  and  some- 
times they  resemble  hypertrophied  tonsils.  They  rarely  if  ever  assume 
the  smooth,  plaque-like  form  of  deposit  beneath  the  mucous  membrane 
of  the  gvit,  such  as  is  seen  in  carcinoma. 

Their  surface  is  always  rough,  unequal,  "  muriform,"  and  the  mu- 
cous membrane  is  movable  over  the  growths  in  their  earlier  stages,  a 
condition  which  distinguishes  them  from  carcinoma. 

They  originate  in  the  submucosa^  and  at  first  appear  as  slightly 
elevated  protrusions  into  the  gut.  As  they  grow  they  may  appear  as 
sessile  tumors,  and  eventually  through  their  own  weight,  friction  of  the 
faecal  mass,  and  the  detrusive  influence  of  the  intestinal  muscles,  develop 
a  distinctly  polypoid  shape. 

They  may  also  appear  as  a  general  fibrous  thickening  of  the  wall  of 
the  gut,  and  thus  be  mistaken  for  simple  inflammatory  stricture  (Gremb, 
Thesis,  Paris,  1887,  No.  231).  Ball  also  records  a  case  of  this  kind 
found  in  the  Dublin  Hospital  Museum. 

The  mucous  membrane  covering  sarcomas  is  at  first  comparatively 
normal.  When  the  tumor  has  grown  so  large  as  to  distend  it  and  sub- 
ject it  to  pressure  and  friction  from  the  faecal  passages,  it  may  become 
congested,  oedematous,  or  ulcerated,  or  it  may  adhere  to  the  growth 
through  inflammatory  processes. 

Number. — Sarcomas  occur  in  the  rectum  singly  or  multiple.  Ball 
(op.  cit.,  p.  325)  has  related  a  case  in  which  there  were  three  distinct 
growths,  and  Heaton  (Path.  Soc,  London)  and  Bowlby  (Brit.  Med.  Jour., 
1894)  have  recorded  cases  in  which  the  growth  appeared  in  the  form 
of  a  large  number  of  small,  disseminated  tumors.    In  one  of  the  author's 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA         801 

cases  there  were  two  tumors:  one  polypoid  and  protruding  from  the 
anus,  the  other  submucous  and  involving  about  half  of  the  circum- 
ference of  the  rectum. 

The  tumors  vary  in  size  from  that  of  a  hazelnut  to  a  good-sized 
orange.  Peterson  has  described  one  as  10  centimeters  (3H  inches)  long 
and  8  centimeters  (3|  inches)  wide,  almost  entirely  occluding  the  lumen 
of  the  gut.  In  a  patient  of  Dr.  Ladinsky's,  in  which  the  tumor  involved 
the  sacrum  and  rectum,  the  rectal  portion  was  as  large  as  a  coconut, 
and  so  filled  up  the  gut  that  it  was  impossible  to  pass  the  finger  beyond 
it.  In  the  case  from  which  Plate  VI,  Fig.  1,  was  made,  the  growth 
was  very  extensive,  but  did  not  protrude  into  the  bowel  to  any  great 
extent.    The  chief  obstruction  which  it  produced  was  at  the  anus. 

Consistence. — To  the  touch,  rectal  sarcomas  are  comparatively  hard, 
but  have  not  the  density  felt  in  scirrhous  cancer.  In  the  spindle  and 
round-cell  varieties,  this  is  not  so  marked  as  in  the  fibro-sarcoma  and 
osteosarcoma,  which  are  very  hard  and  firm  to  the  touch. 

In  the  polypoid  form  they  are  elastic,  with  a  firm  center  resembling 
very  much  the  adenoid  polyp. 

Color. — To  the  eye,  sarcomas  of  the  rectum  present  various  colors. 
Most  frequently  they  appear  like  the  normal  mucous  membrane;  in 
other  cases  they  are  of  a  dark-red  or  grayish  color,  and  when  the  melano- 
sis is  accentuated  they  appear  as  black  gangrenous  masses. 

Where  more  than  one  tumor  exists,  they  may  diiier  materially  in 
appearance,  owing  to  the  changes  in  the  mucous  membrane  and  to  the 
fact  that  melanosis  is  rarely  uniform  in  multiple  growths. 

As  stated  elsewhere,  in  a  case  reported  by  Ball,  one  of  the  tumors 
was  black,  while  the  other  was  pale  and  blanched.  The  first  was  infil- 
trated with  melanin,  while  the  latter  exhibited  no  trace  of  it. 

Site. — Sarcomas  may  occur  at  any  portion  of  the  rectum  or  sigmoid, 
but  the  large  majority  of  them  are  situated  low  down  near  the  anal 
margin.  In  all  of  the  author's  cases  the  growths  were  within  the  lower 
2  inches  of  the  gut,  with  the  exception  of  the  large  one  involving  the 
sacrum,  which  was  as  much  as  2^  inches  from  the  anus. 

The  growth  may  therefore  be  said  to  be  one  of  the  lower  end  of 
the  rectum,  and  is  very  rarely  found  above  the  last  3  inches  of  the  gut. 

Course. — Sarcomas  differ  from  other  neoplasms  of  the  rectum  in  the 
rapidity  of  their  growth.  They  increase  in  size  much  more  rapidly 
than  do  carcinomas,  and  their  fatal  termination  occurs  much  sooner. 

Differing  from  sarcomas  in  other  portions  of  the  body,  those  of  the 
rectum  are  said  to  have  a  distinct  tendency  toward  ganglionic  infection 
(Gillette,  Union  medicale,  1874,  p.  629,  and  Tuffier,  Arch.  genl.  de  med., 
1888,  p.  28).  Early  in  the  disease  the  lymphatic  glands  become  en- 
larged. In  those  cases  in  which  the  tumor  involves  the  margin  of  the 
51 


802  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

anus,  the  inguinal  glands  ^vill  be  the  first  to  become  involved;  in  those 
situated  higher  up  in  the  rectum,  the  sacral,  mesenteric,  and  hypo- 
gastric chains  will  be  the  first  attacked.  Meunier  (Bull.  soc.  d'  anat., 
1875,  p.  792)  reports  a  case  in  which  there  was  a  black,  tar-like  infil- 
tration of  the  vertebral  ganglia,  and  Tuffier  {op.  cit.)  describes  having 
found  a  pigmentary  granulation  in  the  blood  in  cases  of  melanotic  sar- 
coma. This  latter  author,  together  with  Gillette,  insists  upon  the 
glandular  involvement  as  a  diagnostic  symptom  of  the  disease.  Es- 
march,  Grenet,  and  Tedenat  deny  this  tendency  to  glandular  involve- 
ment.   In  the  author's  cases  it  was  present  in  2  and  absent  in  3. 

Metastasis  is  one  of  the  chief  characteristics  of  sarcoma  of  the  rec- 
tum, and  should  always  be  borne  in  mind  in  considering  any  attempt 
at  removal.  The  growth  in  the  rectum  may  be  a  metastatic  deposit 
itself,  or,  being  primary,  it  may  be  associated  with  secondary  develop- 
ments in  other  organs,  either  of  which  conditions  would  contraindicate 
operation.  This  metastasis  is  sometimes  very  widespread,  as  in  the 
case  of  Maier,  where  the  lung,  the  pleura,  the  peritonaeum,  and  the  liver 
were  involved;  in  that  of  Peterson,  the  liver,  the  intestine,  the  kidney, 
and  pancreas;  and  in  that  of  Hamonic,  the  gums  and  the  skin. 

In  one  of  the  author's  cases,  in  which  an  autopsy  was  not  permitted, 
small  sarcomatous  nodules  occurred  over  the  abdomen,  and  extended 
almost  as  high  as  the  axilla;  before  death  the  patient  became  jaundiced, 
apparently  indicating  the  involvement  of  the  liver,  and  one  nodule  de- 
veloped on  the  inferior  maxilla.  On  the  other  hand,  these  cases  occa- 
sionally go  for  considerable  periods  without  any  metastatic  deposits. 

Histology. — There  are  several  different  varieties  of  this  growth  known 
as  round-  or  globe-cell,  spindle-  or  fusiform-cell,  giant-cell,  alveolar,  and 
mixed  sarcomas. 

The  round-cell,  spindle-cell,  and  alveolar  sarcomas  are  the  ones  that 
occur  most  frequently  in  the  rectum,  although  instances  of  the  other 
types  have  been  seen. 

There  is  a  general  impression  that  the  so-called  melano-sarcoma 
represents  a  distinct  variety  of  this  neoplasm.  As  a  matter  of  fact,  any 
one  of  those  enumerated  may  take  on  the  melanotic  change,  which  is 
due  to  the  deposit  of  melanin  in  the  tumor,  giving  it  its  color  and 
name. 

Sarcomas  of  the  rectum,  as  elsewhere,  consist  of  embryonic,  con- 
nective-tissue cells  embedded  in  an  intercellular  substance  which  varies 
in  amount  and  character.  They  contain,  as  a  rule,  very  little  fibrous 
tissue,  the  mass  being  chiefly  composed  of  embryonic  cells.  These  cells 
are  either  uninucleated  or  multinucleated,  and  rarely  possess  a  limiting 
membrane  (Fig.  260). 

The  variety  of  the  tumor  is  determined  by  the  shape,  size,  and  ar- 


LlI 

-h- 
< 
-J 

QL 


MALIGNANT  NEOPLASMS-CARCINOMA  AND  SARCOMA         803 


rangement  of  the  cells.  The  consistence  of  the  tumor  depends  upon 
the  character  of  the  cells,  the  intercellular  substances,  and  the  presence 
or  absence  of  a  fibrous  stroma.  Where  there  is  an  excess  of  fibrous 
elements,  the  tumor  is  spoken  of  as  a  fibro-sarcoma. 

The  blood-vessels  are  very  numerous,  and  are  usually  in  direct  con- 
tact with  the  cells  themselves  or  separated  therefrom  by  a  thin  layer 
of  fibrillary  tissue. 
Their  walls  some- 
times vary  from  the 
normal,  being  com- 
posed of  densely 
packed  embryonic  f^ 
cells,  which,  becom- 
ing detached,  are 
carried  along  the 
channels,  thus  ex- 
plaining the  spread 
of  sarcomata  in  the 
direction  of  the 
blood  current. 

When  the  tumor 
is  of  slow  growth, 
an  apparent  capsule 
of  thin,  fibrous  tis- 
sue may  be  formed 
around  it.  The 
round-,  giant-,  spin- 
dle-cell, and  mixed 
forms  of  sarcoma  are 
usually  easily  recog- 
nized by  the  micro- 
scope. The  alveolar 
variety  is,  however, 
often  confounded 
with  carcinoma.  It 
consists  of  a  fibrous 
stroma  resembling 
that  of  cancer,  which 

separates  the  sarcoma  cells  into  groups.  The  cells  are  perfectly  distinct 
from  the  fibrous  network,  and  are  loosely  adherent;  the  blood-vessels 
follow  the  course  of  the  fibrous  tissue,  and  rarely  if  ever  enter  the  cell 
groups  (Fig.  261).  The  chief  method  of  distinguishing  it  from  carci- 
noma is  by  a  close  examination  of  the  blood-vessels,  the  walls  of  which. 


Fig.  260. — Eound-  and  SprtnjLE-CELLED  Saecoma. 
400  diameters.) 

E,  epidermis ;  P,  papillas,  cut  transversely ;  B,  rete  mucosum ; 
C,  round,  nucleated  sarcoma  corpuscles  ;  <S,  nucleated, 
spindle-shaped  corpuscles ;  B,  blood-vessel :  T,  connective 
tissue. 


804 


THE  ANUS,   RECTUM,  AND  PELVIC  COLON 


iu  sarcoma,  arc  geiicraily  ab.scJil  or  very  thin,  while  iu  the  carcinoma 
we  find  them  either  normal  or  in  the  thickened  state. 

Melanosis  does  not  alter  the  type  of  the  tumor  or  change  the  charac- 
ter of  its  component  parts.  It  may  involve  but  one  part  of  the  tumor, 
while  the  other  portions  remain  perfectly  exempt.  Where  there  are 
several  tumors  or  nodules  in  the  part,  one  may  be  thoroughly  impreg- 
nated with  the  melanin,  while  the  other  remains  perfectly  free. 

Occasionally  haemorrhages  occur  in  these  tumors  owing  to  the  thin- 
ness of  the  blood-vessel  walls,  which  give  them  a  dark  appearance,  and 

may     mislead     one 


into  supposing  that 
they  are  melanotic. 
Coplin  claims 
that  the  haemoglo- 
bin of  such  extrava- 
sated  blood  may 
cause  the  pigmenta- 
tion; Ziegler,  Sten- 
'  gel,  and  other  au- 
thors do  not  con- 
sider this  as  possi- 
ble, and  account  for 
the  pigmentation  in 
other  ways. 

Sarcomas  of  the 
intestine  develop 
from  the  submuco- 
sa,  and  ordinarily 
do  not  affect  the 
mucous  membrane 
except  by  pressure, 
tension,  and  ulcera- 
tion through  trau- 
matism and  infec- 
tion by  the  fa?cal 
mass.  In  its  earlier 
stages,  and  fre- 
quently after  it  has 
attained  consider- 
able size,  the  mu- 
cous membrane  covering  it  retains  its  normal  characteristics,  and  may 
be  easily  moved  about  over  tlie  tumor. 

Etiology. — The  causes  and  influences  which  ])ring  about  the  produc- 


FiG.  261. — Melanotic  Alveolar  Sarcoma. 
(Magnified  400  diameters.) 
P  P,   groups   of  pigmented  corpuscles ;   L,  pigment  clusters ; 
FF,  alveoli,   containing  round,  spindle,  and  pear-shaped 
corpuscles;  C,  capillary  ;  yl,  artery;  T,  connective  tissue. 


PLATE  VII. 


PROCTOSCOPIC  APPEARANCE  AND  SPECIMEN  OF  MEDULLARY  CARCINQMA 


806  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

have  packed  the  rectum  and  tried  to  control  the  haemorrhage  by  styptics 
until  her  circulation  could  have  been  restored  in  a  measure,  but  inef- 
fectual efforts  had  been  made  in  this  line  before  she  was  brought  to 
the  clinic,  and  it  seemed  imperative  that  this  haemorrhage  should  be 
checked  at  once. 

In  the  large  melanotic  sarcoma  shown  in  Plate  VI,  there  was  some 
haemorrhage  in  the  first  few  weeks  of  the  disease,  but  after  that  there 
was  no  loss  of  blood  whatever.  In  the  case  of  J.  S.,  in  which  the  sarcoma 
recurred  at  the  site  from  which  an  adenoma  had  been  removed,  there 
were  profuse  haemorrhages  and  a  considerable  discharge  of  pus.  In  the 
case  of  Mrs.  P.,  there  was  a  marked  discharge  of  mucus  tinged  with 
blood,  but  never  any  haemorrhage. 

One  would  expect  on  account  of  the  thin  blood-vessel  walls  to  meet 
with  excessive  hasmorrhages  from  sarcoma  in  the  rectum,  but  as  the 
irrowth  is  covered  with  normal  mucous  membrane,  which  remains  intact 
until  the  later  stages  of  the  disease,  the  true  sarcomatous  tissue  is  not 
exposed  to  the  friction  and  traumatism  of  the  fwcal  jnass,  and  conse- 
quently the  haemorrhages  are  not  very  frequent,  especially  in  the  early 
stages. 

The  discharge  of  mucus  is  occasionally  seen  with  these  tumors,  but 
it  is  not  so  marked  as  in  o])ithelial  tumors,  ]jecause  the  liypertrophy  is  of 
the  submucous  tissue  and  does  not  involve  the  mucus-producing  cells. 

Protrusion.— Frotrusion  is  more  frequent  in  sarcoma  than  in  car- 
cinoma, but  less  so  than  in  adenomata  and  villous  tumors. 

Where  the  growth  assumes  a  polypoid  shape  and  the  pedicle  is  suf- 
ficiently long,  it  may  come  entirely  outside  of  the  anus.  Even  where 
it  is  sessile  and  situated  just  at  the  margin  of  the  anus,  eversion  or 
prolapse  of  the  lower  end  of  the  gut  may  cause  the  tumor  to  protrude. 

Where  the  tumor  is  pedunculated  and  thus  protrudes,  severe  haemor- 
rhages may  occur  on  account  of  its  being  ])artially  strangulated  by  the 
sphincter  muscles. 

Where  the  growth  is  of  the  melanotic  variety,  it  may  be  mistaken 
for  a  gangrenous  ha-morrhoid.  On  the  other  hand,  even  though  mela- 
notic in  its  center,  the  surface  of  the  tumor  may  have  a  pale,  yellowish- 
red  color,  resembling  an  epithelioma.  Such  was  the  case  in  one  of  the 
author's  patients,  in  whom  Dr.  Jeffries  and  he  both  mistook  the  growth 
for  an  epithelioma. 

Odor. — There  is  no  odor  peculiar  to  sarcoma.  Before  ulceration  of 
its  mucous  surface  takes  place  there  is  nothing  more  than  the  ordinary 
normal  faecal  odor  to  the  parts.  After  the  ulceration  has  occurred, 
however,  and  there  is  a  production  of  pus,  it  changes  to  that  of  decom- 
posing tissue,  but  never  assumes  that  peculiar  characteristic  and  dis- 
gusting odor  which  one  finds  in  carcinoma  of  the  rectum. 


PLATE  VII 


EPITHELIOMA  OF  SIGMOID 


EPITHELIOMA 
OF  SIGMOID 
'proctoscopic! 


EPITHELIOMA 

WITH    ULCERATION 

(proctoscopic) 


MALIGNANT    NEOPLASMS 


MALIGNANT  NEOPLASMS— CARCINOMA  AND  SARCOMA        80 Y 

Pain. — The  amount  of  pain  which  a  patient  suffers  with  sarcoma 
depends  very  largely  upon  its  site.  If  it  is  low  down  and  involves  the 
sphincter,  thus  inducing  persistent  contraction  and  pressure,  the  patient 
will  suffer  greatly,  but  if  it  is  high  up  in  the  rectum  and  of  an  infil- 
trating form,  he  may  go  on  almost  to  the  very  end  without  any  knowl- 
edge of  his  grave  condition.  This  symptom  is  therefore  a  very  un- 
reliable one. 

The  State  of  the  Bowels. — The  state  of  the  bowels  in  sarcoma  of  the 
rectum  also  varies  according  to  the  type  of  the  tumor;  in  some  cases 
constipation  is  complained  of  persistently,  whereas  in  others  diarrhoea 
is  almost  uncontrollable. 

In  the  large  melanotic  sarcoma,  from  which  the  plate  was  made, 
this  woman  restrained  the  movements  of  her  bowels  on  account  of  the 
pain,  and  thus  developed  an  inveterate  constipation.  In  the  case  in 
which  the  sarcoma  followed  the  removal  of  the  adenoma,  this  patient 
suffered  from  a  diarrhoea  which  one  could  not  say  positively  came  from 
the  sarcoma,  because  the  man  had  two  adenomas  higher  up  in  the  rec- 
tum which  might  have  accounted  for  it. 

General  Symptoms. — Flatulence,  indigestion,  loss  of  appetite  and 
weight  are  associated  with  sarcoma  of  the  rectum,  as  they  are  with  all 
other  neoplasms  of  this  organ. 

Cachexia  is  not  so  marked  as  in  carcinoma  and  villous  tumor.  The 
reflex  digestive  disturbances  are  quite  as  severe.  Decrease  in  strength, 
loss  of  flesh,  swelling  of  the  feet  and  abdomen  rapidly  succeed  one 
another  when  the  sarcoma  is  once  well  developed. 

Dysuria  is  frequently  present,  and  complete  suppression  due  to 
involvement  of  the  kidney  may  occur.  The  lungs  and  pleura  may 
become  affected,  presenting  symptoms  of  acute  pleuro-pneumonia, 
and  the  patient  finally  succumbs  to  progressive  anaemia  and  ex- 
haustion. 

Diagnosis. — Sarcoma  is  to  be  distinguished  from  carcinoma,  adenoma, 
fibroma,  and  villous  tumor.  It  is  more  pedunculated  than  carcinoma, 
and  less  so  than  adenoma.  It  is  more  firm  than  the  adenoma  and  less 
so  than  carcinoma. 

In  its  attachment  to  the  gut  it  does  not  involve  so  large  an  area, 
and  it  does  not  spread  out,  producing  that  wide  infiltration  of  the 
walls  like  carcinoma.  Its  attachment  is  very  abrupt,  and  one  can  gen- 
erally limit  the  extent  of  the  growth  very  positively  and  clearly. 

To  the  touch  it  is  more  undulating  and  spherical  than  carcinoma, 
and  the  dendritic  divisions  which  one  finds  in  villous  tumor  and  ade- 
noma are  absent.  One  may  recall  the  fact  that  simple  adenomas  occur 
largely  in  children,  whereas  sarcoma  is  a  disease  of  middle  or  advanced 
age;  nevertheless,  it  is  occasionally  found  in  the  young. 


808  THE   ANUS,   RECTUM,  AND   PELVIC  COLON 

Wlien  it  is  a  question  between  sarcoma  and  multiple  adenoma,  the 
very  multiplicity'  of  the  growths,  the  excessive  diarrhoea,  together 
with  the  comparatively  fair  condition  of  the  patient's  health,  may  be 
mentioned  upon  the  side  of  adenoma.  Between  sarcoma  and  carci- 
noma the  distinct  odor  of  carcinoma  is  enough  to  make  the  decision 
positive. 

In  the  early  stages  of  sarcoma,  the  fact  that  the  mucous  membrane 
moves  easily  over  the  growth  distinguishes  it  almost  positively  from 
carcinoma.  The  final  test,  however,  depends  upon  the  microscopic  ex- 
amination of  a  section  of  the  growtli.  It  will  not  do,  however,  to  depend 
upon  any  superficial  portion  in  order  to  make  this  diagnosis.  The 
growth  is  a  submucous  one,  and  the  section  to  be  reliable  must  be 
taken  from  the  substance  of  the  tumor  itself  and  not  from  the  super- 
ficial nmcous  covering.  It  is  inadvisable  to  make  any  incision  into  these 
growths  for  the  purpose  of  obtaining  a  section,  unless  the  case  is  an 
operable  one  and  the  patient  consents  to  a  removal,  if  the  microscopic 
examination  should  show  a  necessity  for  the  same. 

Any  mechanical  irritation  or  interference  with  such  growths  only 
stimulates  their  progress  and  hastens  the  end,  unless  they  are  radically 
extirpated. 

Treatment. — The  treatment  of  these  tumors  consists  in  their  radical 
removal.  A  ligature  to  pedunculated  sarcomas  ought  never  to  be  con- 
sidered for  one  instant.  The  growth  extends  into  the  submucosa,  and 
the  ligature  is  sure  to  leave  behind  it  portions  of  the  disease.  The 
tumor  should  be  removed  radically  and  widely  at  its  base.  If  it  is 
situated  in  the  ampulla  and  limited  in  extent,  posterior  proctotomy  may 
enable  one  to  excise  it  thoroughly  and  bring  the  edges  of  the  wound 
together;  but  if  it  is  extensive  and  diffused,  involving  much  of  the  cir- 
cumference of  the  rectum,  total  excision  or  resection  of  the  organ  is 
the  only  recourse  available.  The  technique  of  these  operations  will  be 
described  in  the  chapter  on  Extirpation. 

While  there  seems  to  be  some  evidence  in  favor  of  the  effective- 
ness of  the  serum  therapy  in  sarcomas  elsewhere,  the  advocates  of  this 
method  give  no  encouragement  in  the  treatment  of  this  condition  in 
the  rectum.  Eecent  experiments  in  the  use  of  the  X-ray  in  the  treat- 
ment of  sarcoma  give  some  encouragement  to  hope  that  this  line  of 
treatment  may  prove  successful  in  this  disease.  In  the  present  state 
of  our  knowledge  the  author  believes  that  it  would  be  a  wise  precaution 
in  inoperable  cases,  or  even  after  the  tumor  has  been  removed,  to  apply 
the  rays  to  the  seat  of  the  disease.  If  cautiously  employed,  no  harm 
can  result  from  it,  and  it  is  possible  that  recurrence  may  thus  be  pre- 
vented. 

Prognosis. — The  prognosis  in  sarcoma  of  the  rectum  is  exceedingly 


MALIGNANT  NEOPLASMS— CAKCINOMA  AND  SARCOMA        809 

grave.  Its  tendency  is  toward  a  wide  metastasis  and  rapid  fatality.  Very 
few  of  the  cases  survive  more  than  one  year  after  operation.  Paul  (Brit. 
Med.  Jour.,  1895,  vol.  i,  p.  519)  has  reported  a  case  living  without  re- 
currence one  year,  Bernays  (Jour,  iimer.  Med.  Ass'n,  April  3,  1897)  one 
five  years.  Ball  (Brit.  Med.  Jour.,  1895,  p.  693)  one  nine  years,  and 
Esmarch  (Deutsch.  Chirurg.,  Bd.  v,  S.  516)  one  five  years.  The  author 
reported  a  case  to  the  Chicago  Academy  of  Medicine  in  January,  1897, 
which  is  still  free  from  recurrence  five  and  a  half  years  after  operation, 
and  in  perfect  health.  The  patient  from  whom  the  extensive  melano- 
sarcoma  shown  in  Plate  VI  was  removed  September  21,  1899,  was  living 
and  well  two  years  after  the  operation.  The  microscopical  examinations 
of  these  cases  were  made  by  Drs.  Heitzmann,  Vissman,  and  Jeffries,  and 
there  can  be  no  doubt  as  to  the  pathological  nature  of  the  growths.  One 
was  l}Tnpho-sarcoma,  the  other  melanotic  spindle-cell  sarcoma.  These 
cases,  while  few,  show  that  extirpation  of  these  growths  is  not  utterly 
hopeless. 


CHAPTEK    XX 
EXTIRPATION  OF  THE  RECTUM 

The  operation  of  removing  the  rectum  is  now  almost  two  centuries 
old.  Faget  performed  it  in  1739,  but  Lisfranc  first  successfully  ex- 
tirpated the  rectum  for  cancer  in  1826.  The  results  of  the  operation 
in  9  cases  were  embodied  in  a  thesis  by  one  of  his  students  (Pinault, 
Thesis,  Paris,  1829,  No.  167),  and  in  1833  the  great  surgeon  himself 
gave  to  the  world  a  complete  account  of  his  operation  and  method, 
thus  establishing  the  procedure  as  a  surgical  measure  (Memoires  de 
I'academie  royale  de  medecine,  1833,  t.  ii,  p.  296).  The  results  in 
these  cases  were  not  calculated  to  create  any  great  enthusiasm,  for  the 
mortality  was  high  owing  to  the  lack  of  aseptic  technique;  nevertheless, 
surgeons  oscillated  in  their  opinions  between  this  operation  and  thera- 
peutic measures  for  the  next  half  century.  As  late  as  1876  Sir  Henry 
Smith  said:  "  I  should  have  thought  this  "  (excision  of  cancer  of  rectum) 
"  was  entirely  a  part  of  the  surgery  of  a  bygone  age,  and  that  the 
recorded  experience  of  those  who  had  performed  these  operations  in 
France  and  in  this  country  would  have  sufficed  to  put  an  end  to  all 
such  barbarism." 

Up  to  this  period  the  operation  had  been  confined  to  growths  low 
down  in  the  rectum,  and  was  performed  either  through  perineal  in- 
cision or  through  the  anus  itself.  Verneuil,  adopting  the  suggestion 
of  Amussat,  first  practised  the  removal  of  the  coccyx  to  obtain  better 
access  to  the  tumor,  but  the  operation  attained  only  slight  popularity 
until  Kraske's  epoch-making  paper  before  the  fourteenth  congress  of 
German  surgeons  in  Berlin  in  1885.  His  suggestion  to  remove  a  portion 
of  the  sacrum,  in  order  to  reach  neoplasms  involving  the  upper  portion 
of  the  rectum,  revolutionized  the  surgery  of  these  parts,  and  gave  an 
impetus  to  the  operation  of  extirpation  which  has  probably  carried  us 
for  a  time  beyond  the  limits  of  true  conservatism.  Soon  after  the  an- 
nouncement of  Kraske,  man}^  surgeons,  notably  Hochenegg  and  Bar- 
denheuer,  advocated  removing  larger  portions  of  the  sacrum  so  as  to 
widen  the  field  of  operation.  This  tendency  reached  its  maximum  in 
the  method  of  Rose,  which  practically  obliterated  the  entire  bony  floor 
810 


EXTIRPATION  OF  THE  RECTUM  811 

of  the  pelvis.  In  order  to  obviate  tliis  feature,  Levy,  Eehn,  Rydygier, 
and  Billroth  proposed  to  make  bone-flaps  containing  the  coccyx  and 
lower  segments  of  the  sacrmn,  which  would  be  sutured  back  into  posi- 
tion after  the  rectum  was  extirpated. 

ilbout  this  time  Desguins  first  employed  the  vaginal  route  in  extir- 
pation of  rectal  cancer  (xVnnales  de  la  soc.  de  med.,  D'Anvers,  September, 
1890).  Price  (Med.  and  Surg.  Reporter,  May  16,  1896)  and  Arthur 
(Amer.  Jour,  of  Obstet.,  1881,  vol.  xxiv,  p.  567)  had  previously  made 
use  of  the  vagina  as  a  point  for  the  implantation  of  the  gut  after  extirpa- 
tion of  the  rectum  where  it  was  impossible  to  bring  it  down  and  suture 
it  to  the  margin  of  the  anus,  but  neither  of  them  suggested  attacking 
the  growth  through  this  canal. 

Later  on  in  1891:  and  1896,  Giordano  and  Quenu  (Clinica  Chirurg., 
Milano,  1896,  f.  463;  Chirurgie  du  rect.,  t.  ii,  p.  290)  found  it  difficult  to 
control  haemorrhage  and  dissect  out  the  enlarged  ganglions  above  the 
sacral  prominence  by  the  foregoing  methods,  and  advocated  opening  the 
abdomen,  loosening  the  attachments  of  the  upper  rectum  and  sigmoid, 
and  the  establishment  of  an  artificial  anus;  after  this  the  rectum  was 
dissected  out  from  below  either  through  the  perineal  or  sacral  route. 
These  efforts  created  what  is  known  as  the  combined  method  for  extir- 
pation of  the  rectum.  They  were  preceded,  however,  in  this  method 
by  Maunsell,  who  advised  in  1892  a  laparotomy  to  loosen  the  upper  rec- 
tum and  sigmoid  from  their  attachments  to  the  sacrum,  the  invagina- 
tion of  the  growth  through  the  anus,  and  resection  of  the  neoplasm 
thus  brought  outside  of  the  body.  Recently  extirpation  through  the 
abdominal  route  alone  has  been  advocated  by  Mann  and  Edebohls. 

From  this  brief  sketch  it  will  be  seen  that  there  are  five  general 
methods  of  accomplishing  extirpation — the  perineal,  the  sacral,  the 
vaginal,  the  abdominal,  and  the  combined. 

Prefaration  of  the  Patient. — Before  describing  these  methods  in  de- 
tail it  may  be  well  to  consider  the  preparation  of  the  patient,  which 
is  practically  the  same  in  each.  In  order  to  obtain  the  best  results  it 
is  necessary  to  increase  the  patient's  strength  as  far  as  possible  by 
forced  feeding  for  a  time,  to  empt}^  the  intestinal  tract  of  all  hard  and 
putrefying  faecal  masses,  to  establish  as  far  as  we  may  intestinal  anti- 
sepsis, and  to  check  in  a  measure  the  purulent  secretion  from  the  growth. 

It  requires  from  seven  to  ten  days,  or  longer,  to  properly  prepare  a 
patient  for  this  operation.  The  diet  best  calculated  to  obtain  a  proper 
condition  of  the  intestinal  tract  is  generalh^  conceded  to  be  a  nitroge- 
nous one.  The  absolute  milk  diet  is  not  so  satisfactory  as  a  mixed  diet 
composed  of  meat,  strong  broths,  milk,  and  a  small  quantity  of  bread 
and  refined  cereals.  The  patient  should  be  fed  at  frequent  intervals, 
and  as  much  as  he  can  digest.    Along  with  this  forced  feeding  one  should 


812  THE   ANUS,   RECTUM.   AND   PELVIC   COLON 

administer  daily  a  saline  laxative  which  will  produce  two  or  three  thin 
movements,  and  to  disinfect  the  intestinal  canal  one  should  give  through 
the  stomach  three  or  four  times  a  day  either  sulphocarholate  of  zinc, 
grs.  ijss.  in  the  form  of  an  enteric  pill;  naphthalene,  grs.  xv  in  a  capsule; 
beta-naphthol,  grs.  x,  or  salol,  grs.  x,  in  the  same  manner.  The  rectum 
should  be  irrigated  three  times  a  day  with  solutions  of  bichloride  of 
mercury  1  to  5,000,  permanganate  of  potash  1  to  1,500,  or,  as  has  been 
recommended  by  Quenu  (Soc.  de  chir.,  February  23,  1898),  peroxide 
of  hydrogen.  This  solution  is  made  by  mixing  one  part  of  the  peroxide 
of  commerce  with  three  to  four  parts  of  boiling  water.  Quenu  states 
that  it  causes  no  irritation  in  the  mucous  membrane,  that  it  deodorizes 
the  cancer  in  a  few  hours,  that  its  action  is  persistent,  and  that  it  de- 
stroys the  micro-organisms  more  effectually  than  any  other  substance. 
On  the  day  previous  to  the  operation  the  perinaeum,  sacral  region, 
and  pubis  should  be  shaved,  dressed  with  a  soap  poultice  for  two  hours, 
then  washed  and  dressed  with  a  bichloride  dressing,  which  should  be 
retained  until  the  patient  has  been  anaesthetized.  Notwithstanding  all 
these  preparations  it  is  impossible  to  obtain  absolute  asepsis  of  the 
affected  area,  and  so  many  fatalities  occur  from  infection,  either  during 
the  operation  or  through  the  giving  way  of  the  sutures  and  pouring  out 
of  the  intestinal  contents  into  the  wound,  that  it  is  deemed  wise  by 
many  surgeons  to  make  an  artificial  inguinal  anus  as  a  preliminary  pro- 
cedure in  all  extirpations  of  the  rectum.  Schede  (Deutsch.  med.  Woch., 
Leipzig,  1887,  S.  10-18)  first  took  this  precaution,  making  the  colotomy 
at  the  same  time  that  he  extirpated  the  rectum,  thus  diverting  the  fajcal 
current  from  the  operative  field  and  reducing  the  chances  of  sepsis  from 
this  source.  This  method  has  been  largely  adopted  by  surgeons  all  over 
the  world;  some  make  a  permanent  inguinal  anus  to  begin  with,  closing 
up  the  distal  end  of  the  sigmoid  and  dropping  it  back  into  the  intestinal 
cayity,  where  it  is  either  left  or  removed  along  with  the  cancer  (Keen, 
Jour.  Am.  Med.  Assoc,  1898);  others  make  a  temporary  inguinal  anus, 
which  is  closed  later  on  if  it  is  found  feasible  to  restore  the  faecal  exit 
to  its  normal  position  at  the  anus.  Some  advise  making  this  anus  in 
the  sigmoid,  others  in  the  transverse  colon,  and  still  others  in  the 
ascending  colon  just  above  the  caecum.  The  wisdom  of  this  precaution 
can  not  be  questioned  in  very  many  cases,  but  its  necessity  is  open  to 
debate.  It  involves  either  a  threefold  operation  or  the  establishment 
of  a  permanent  inguinal  anus,  both  of  which  are  to  be  avoided  if  possi- 
ble; and  if  it  is  made  in  the  sigmoid  it  may  prevent  the  gut  being  brought 
down  sufficiently  to  reestablish  the  intestinal  canal.  The  question  there- 
fore arises,  "VMien  is  this  procedure  necessary?  It  appears  to  the  author 
that  where  the  cancer  is  low  down  and  the  caliber  of  the  gut  is  sufficiently 
great  to  enable  one  to  thoroughly  empty  the  intestinal  canal  of  all  faecal 


EXTIRPATION  OF  THE  RECTUM  813 

accumulations  above  it,  where  it  is  perfectly  clear  before  beginning  the 
operation  that  one  will  be  able  to  bring  the  gut  down  from  above  and 
suture  it  to  the  margin  of  the  anus,  this  procedure  is  not  indicated. 
When  there  is  any  doubt  with  regard  to  the  possibility  of  accomplishing 
this  latter  operation,  the  preliminary  artificial  anus  ought  always  to  be 
made.  The  author  is  opposed,  however,  to  making  a  permanent  colos- 
tomy except  in  those  cases  where  the  extent  of  the  growth  renders  it 
certain  that  the  normal  fsecal  tract  can  not  be  restored.  A  preliminary 
artificial  anus  that  may  be  readily  closed  can  be  easily  made  if,  after 
manual  examination  of  the  pelvic  cavity,  one  is  persuaded  that  he  can 
extirpate  the  cancer  and  restore  the  intestinal  tract.  In  the  chapter 
on  Colostomy  the  manner  of  accomplishing  this  is  thoroughly  explained. 
If  after  extirpation  it  is  found  that  the  intestinal  tract  has  not  been 
restored,  it  is  always  possible  to  convert  the  temporary  into  a  perma- 
nent artificial  anus  with  comparatively  no  danger  to  the  patient.  In  the 
33  cases  operated  upon  by  the  author,  artificial  ani  have  been  made  in 
10  cases.  Of  these,  3  resulted  fatally,  thus  giving  a  slightly  higher 
mortality  than  that  obtained  in  operations  without  preliminary  colot- 
omy.  It  is  not  meant  by  this  to  claim  for  one  instant  that  the  arti- 
ficial anus  increases  the  mortality  from  extirpation.  The  author  firmly 
believes  that  if  it  were  consistently  employed  in  every  extirpation  of 
the  rectum,  the  mortality  from  this  operation  might  be  slightly  reduced; 
but  he  also  holds  that  in  the  class  of  cases  mentioned  above  the  two 
additional  operations  can  be  avoided  with  comparative  safety.  "\\^ere 
the  artificial  anus  is  employed,  one  should  not  be  in  too  great  haste  to 
carry  out  the  extirpation.  A  period  of  ten  days  or  two  weeks  should 
be  allowed  to  elapse  between  the  two  operations.  During  this  time 
the  rectum  should  be  irrigated  through  the  lower  end  of  the  artificial 
anus  and  through  the  anus  with  antiseptic  solutions,  and  at  the  same 
time  one  may  take  advantage  of  this  period  to  employ  forced  feeding, 
tonics,  and  stimulating  remedies  to  improve  the  patient's  general  con- 
dition and  better  prepare  him  to  withstand  the  shock  of  operation. 

It  has  been  suggested  by  E.  H.  Taylor  (Ann.  of  Surg.,  1897,  vol.  1, 
p.  385),  that  where  the  cancer  is  soft  and  ulcerated,  one  may  employ 
curettage  to  remove  the  sloughing  and  suppurating  portions  of  the 
growth,  following  this  for  a  few  days  by  frequent  irrigations,  and  then 
carrying  out  an  extirpation  by  whatever  method  is  deemed  best.  This 
procedure  has  not  been  generally  adopted  by  surgeons,  and  possesses 
no  advantages  over  the  preliminary  artificial  anus. 
r  Peeixeal  Method. — Under  this  method  may  be  included  certain 
operations  for  small  epitheliomas  low  down  in  the  rectum  done  through 
the  anus.     The  procedure  is  carried  out  as  follows: 

The  patient  having  been  properly  prepared,  the  sphincter  is  thor- 


814  THE  ANUS,   RECTUM,  AND   PELVIC  COLON 

oiighly  dilated;  a  circular  incision  through  the  entire  wall  of  the  gut 
is  made  half  an  inch  below  the  neoplasm;  this  incision  may  entirely 
surround  the  rectum,  or  it  may  be  limited  to  half  the  circumference 
when  the  growth  is  confined  to  one  side;  the  upper  segment  of  the  gut  is 
then  caught  with  traction  forceps  and  dragged  upon  by  an  assistant  while 
the  operator  frees  it  by  scissors  and  blunt  dissection  to  a  point  at  least 
half  an  inch  above  the  cancer;  it  is  then  cut  transversely  well  above  the 
growth,  the  upper  segment  being  caught  by  forceps  to  prevent  retraction; 
finally,  this  end  is  brought  down  and  sutured  to  the  lower  edges  of  the 
original  incision  (Ledru,  Cong.  Franc,  d.  chirurg.,  1891,  p.  319;  Hart- 
mann,  ibid.,  1893,  p.  698;  Eoutier,  Exerese  dans  le  cancer  du  rectum; 
Finet,  p.  204).  The  cases  to  which  this  method  is  applicable  are  very 
rare;  moreover,  the  procedure  is  open  to  the  objections  that  it  is  very 
likely  to  be  followed  by  septic  infection,  and  furnishes  no  opportunity 
to  remove  any  affected  glands. 

Numerous  methods  have  been  devised  by  various  surgeons  for  ex- 
tirpation of  the  rectum  by  the  perineal  route  proper.  The  old  operations 
of  Lisfranc,  Dieffenbach,  Velpeau,  and  Yerneuil  are  no  longer  em- 
ployed. The  V-shaped  incision  of  Schelky  (Berlin,  klin.  Woch.,  1892, 
No.  32),  the  lateral  incision  of  Hartmann  through  the  ischiatic  fossa 
(Quenu  and  Hartmann,  op.  cit.,  t.  ii,  -p.  249),  and  the  H-shaped  in- 
cision of  Dejjage  (Ann.  d.  1.  soc.  Beige  d.  chir.,  1893,  No.  6),  are  all 
to  be  rejected  on  account  of  the  vast  areas  of  tissue  laid  open  and  the 
unsatisfactory  access  to  the  rectum  which  they  give. 

The  methods  of  Cripps  and  Allingham  have  long  been  very  popular 
in  extirpation  of  cancers  in  the  lower  portion  of  the  rectum. 

Cripps's  Method. — A  long,  sharp-pointed,  curved  bistoury  is  intro- 
duced through  the  anus  and  made  to  penetrate  from  within  outward  at 
the  tip  of  the  coccyx;  all  of  the  intervening  tissues  are  then  cut  through, 
thus  laying  the  rectum  open  up  to  this  point;  lateral  incisions  are  then 
made  around  each  side  of  the  rectum,  either  through  the  skin  outside 
of  the  sphincter  or  through  the  mucous  membrane  above  the  muscle, 
according  to  whether  the  anus  is  involved  in  the  neoplasm  or  not;  these 
incisions  should  be  made  deep  and  boldly  at  one  sweep,  the  wounds 
being  immediately  packed  with  gauze  to  control  haemorrhage;  after  this 
the  rectum  is  freed  from  its  lateral  and  posterior  attachments  by  scissors 
and  dull  dissection  to  a  point  well  above  the  cancer;  these  parts  of  the 
wound  are  then  packed  with  gauze  and  the  rectum  is  dissected  off  an- 
teriorly from  the  perinseum,  urethra,  and  prostate;  this  step  is  some- 
what difficult,  and  a  good-sized  sound  should  be  kept  in  the  urethra 
during  the  procedure  in  order  to  avoid  wounding  this  organ.  If  the 
growth  is  limited  to  one  side  of  the  rectum,  only  this  portion  is  dis- 
sected out.     After  the  dissection  is  completed  the  gut  is  amputated 


EXTIRPATION   OF   THE  RECTUM 


815 


aboye  the  growth  by  a  wire  ecraseur  or  a  galvano-cautery  loop.  Unless 
the  growth  is  very  low,  no  attempt  is  made  to  bring  the  gut  down  and 
suture  it  to  the  anus,  but  a  drainage-tube  is  introduced  into  the  upper 
segment,  and  after  the  hemorrhage  is  controlled  the  wound  is  packed 
with  sterilized  gauze.  The  gap  between  the  anus  and  excised  gut  is 
left  to  heal  by  granulation. 

AlUngliam's  Method. — The  chief  feature  of  this  procedure  consists  in 
a  deep  dorsal  incision;  with  the  left  index  finger  in  the  rectum,  a  long, 
narrow  bistoury  is  introduced  through  the  skin  just  posterior  to  the 
anus  and  carried  through  the  post-rectal  tissues  above  the  upper  limits 
of  the  growth  entirely  outside  of  the  rectum;  the  tissues  between  this 
and  the  sacrum 
and  coccyx  are  in- 
cised from  this 
point  downward  at 
one  stroke ;  the 
wound  is  packed 
with  sponges  to 
control  the  bleed- 
ing; an  incision  is 
then  made  all 
around  the  rec- 
tum (Fig.  262)  and 
between  the  two 
sphincters  if  the 
anus  is  not  in- 
volved, and  the  external  muscle  is  incised  at  the  posterior  commis- 
sure; the  muscle  is  thus  left  in  the  skin-tlaps;  with  the  finger  in  the 
rectum  one  blade  of  a  long  scissors  is  introduced  into  the  posterior 
wound,  the  other  is  thrust  into  the  ischio-rectal  fossa,  and  the  in- 
tervening cellular  tissues  cut  through.  Each  side  is  treated  in  the 
same  manner,  and  the  wounds  packed  with  sponges.  The  outer  edges 
of  the  Avounds  being  held  apart  by  broad,  flat  retractors  (Fig.  263), 
the  surgeon  then  proceeds  to  dissect  the  anterior  portion  of  the 
rectum  loose  from  its  attachments.  A  sound  should  be  held  in  the 
urethra  in  men  and  an  assistant's  finger  in  the  vagina  in  women  to 
prevent  wounding  these  organs.  After  the  gut  has  been  dissected  out 
well  above  the  tumor,  it  is  caught  by  rectangular  clamps  and  cut  off 
below  these.  Bleeding  is  controlled  by  ligatures  and  equal  parts  of  hot 
water  and  alcohol.  Allingham  states  {op.  cif.,  p.  358):  "In  most  of  our 
cases  it  was  absolutely  impossible  to  bring  down  the  stump  of  the  rectum 
to  the  skin;  if,  indeed,  these  parts  could  be  brought  together,  the  ten- 
sion would  be  so  great  that  the  sutures  would  be  torn  out  in  a  few 


Fig.  262. — Lixe  of  Incision  in  Pekixeal  Proctectoiit  by 
Allingham's  Method. 


816 


THE  ANUS,   RECTUM,  AND   PELVIC  COLON 


Fig.  263. — Second  Step  in  Allingham's  Method  (Mathews). 

hours."    The  rapidity  with  which  this  operation  can  be  done  and  the 
preservation  of  the  external  sphincter  comprise  its  chief  advantages. 

These  operations  are  open  to  the  same  objections:  they  do  not  remove 
the  affected  ganglions,  they  leave  a  section  of  the  rectum  to  be  repro- 


Fii-..  '-''-i       •':  ;,iM  Ai.  K\  1  iia'ATiox  OF  THE  Rectum  (Quenu's  method). 
R,  rectum;    E,   external   sphincter;    C,  coccy.v;    T,  traiisvei'sus   pennei   muscles;  A,  bulbous 

urethra. 


EXTIRPATION   OF   THE  RECTUM 


817 


duced  by  granulation,  and  tliey  inevitably  lead  to  infection  and  pro- 
longed suppuration.  For  this  reason  the  writer  no  longer  practises 
them. 

Eecognizing  the  facts  that  the  mortality  from  extirpation  of  the 
rectum  by  the  perineal  route  is  much  lower  than  by  any  other  method, 
and  that  the  deaths  are  largely  due  to  sepsis  following  the  operation, 
surgeons  have  long  sought  to  devise  for  this  measure  some  efficient 
antiseptic  technique.  Infection  occurs  during  the  operation  from  intro- 
ducing the  finger  into  the  rectum  and  then  into  tlie  wound,  or  from 
cutting  or  tearing  the  rectal  wall  so  that  its  contents  flow  out  into  the 


/ 


I 


Fig.  265. — Perineal  Extirpations' — loosening  KECTUii  from  Anterior  I'erineal  Khaphe. 
Z,,  levator  ani ;  E,  rectum  ;  J/,  rhaphe. 


operative  field;  after  the  operation  it  occurs  from  the  passage  of  f^ces 
over  the  fresh  wound.  In  order  to  avoid  the  latter,  a  preliminary  arti- 
ficial anus  may  be  employed.  To  avoid  the  former,  one  must  absolutely 
close  the  lower  end  of  the  rectum  and  keep  well  away  from  the  wall  of 
the  gut  in  his  dissections.  These  ends  are  largely  accomplished  by  the 
technique  of  Quenu  (Eev.  de  gynec,  September  and  October,  1898). 
With  some  slight  modifications  introduced  by  the  writer,  this  proceeding 
is  as  follows: 

The  patient,   after  being  properly   prepared,   is   anaesthetized  and 
placed  in  the  lithotomy  position,  the  hips  being  well  elevated  above  the 
52 


81.8 


THE  ANUS,  RECTUM,  AXD  PELVIC  COLON 


shoulders  by  cushions  or  inclination  oi'  the  table;  the  ivctuui  is  then 
irrigated,  dried  out,  and  loosely  packed  with  gauze  in  order  that  one 
may  recognize  a  close  approach  to  its  walls  during  dissection;  a  circular 
incision  is  then  made  through  the  skin  around  the  anus,  and  this  is  dis- 


FlG.    iGG. — I'jililXJi.VL    ii.VIUM'.VTloX. 

B,  rectum;  i,  levator  ani ;  (?,  ueoplasin  ;  P,  peritoneal  pouch  ;  S,  seminal  vesicles  and  prostate. 

sected  up  inside  of  the  sphincter  to  the  extent  of  about  ^  an  inch. 
Around  the  cylinder  thus  dissected  loose  a  strong  silk  suture  is  tied, 
the  ends  of  which  are  left  long  for  purposes  of  traction  (Fig.  264);  the 
extremity  of  the  anus  below  the  ligature  is  then  cauterized  with  a 
Paquelin  blade  to  destroy  any  infectious  germs  which  it  may  contain. 
The  external  sphincter  is  then  incised  anteriorly  and  posteriorly  en- 
tirely outside  of  the  rectum,  the  posterior  incision  being  carried  back 
to  the  tip  of  the  coccyx  and  well  into  the  retro-rectal  space;  the  rectum 
is  then  dissected  from  its  attachments  laterally  and  posteriorly,  the 
sphincter  being  left  in  the  skin-flaps,  if  it  is  not  involved  in  the  growth; 
in  doing  this  the  levator  ani  muscle  should  be  cut  off  as  close  to  the 
rectum  as  possible  (Fig.  265).  The  skin  and  sphincter  muscle  having 
been  incised  in  the  median  line  anteriorly  as  far  as  the  junction  with 
the  scrotum,  the  rectum  is  drawn  backward  and  dissected  loose  an- 
teriorly up  to  the  level  of  the  levator  ani,  which  is  much  higlier  here 
than  posteriorly.     The  finger  is  then  introduced  from  behind  forward 


EXTIRPATION   OF  THE  RECTUM 


819 


above  the  anterior  fibers  of  the  levator  and  the  deep  jjerineai  fascia, 
and  by  gently  dragging  downward  these  are  separated  from  the  rectum 
in  the  lines  of  cleavage;  when  this  has  been  accomplished  on  both  sides, 
the  anterior  attachment  of  the  levator  and  ano-bulbar  rhaphe  to 
the  rectum  are  cut  through  upon  the  finger,  and  the  organ  is  thus 
freed  in  its  entire  circumference.  This  accomplished,  the  operator 
reaches  the  superior  pelvi-rectal  spaces  filled  with  cellular  tissue,  from 
which  the  rectum  can  be  separated  by  the  finger  until  the  peritoneal 
cul-de-sac  is  reached  in  front  (Fig.  266).  At  this  point  the  lateral  con- 
nective-tissue folds  Avhich  support  the  rectum  on  the  sides  must  be 
clipped  with  scissors,  and  then  the  gut  will  descend  well  outside  of  the 
wound.  Sometimes  the  peritonaeum  can  be  stripped  off  from  the  rectum 
and  its  cavity  need  not  be  opened;  it  is  better,  however,  to  open  the 
cavity  at  once  when  the  growth  extends  above  this  point.  Before  doing 
this  it  is  well  to  disarticulate  the  coccyx  and  fold  it  backward  in  order  to 
obtain  more  room,  and  separate  the  rectum  from  the  sacrum  by  break- 


FiG.  267. — Perineal  Extirpation — the  Peritoneal  Polcii  laid  open. 

ing  up  the  cellular  and  fibrous  attachments  with  the  fingers.  The  peri- 
toneum is  then  incised  (Fig.  267),  cut  loose  from  its  attachments  close 
to  the  rectum  back  to  the  mesoreetum  (Fig.  268),  which  should  be  cut 
close  to  the  sacrum  in  order  to  avoid  wounding  the  inferior  mesenteric 
artery.    When  the  gut  has  been  loosened  sufficiently  above  the  tumor 


820 


THE  ANUS,   RECTUM,  AND  PELVIC  COLON 


to  be  brou^iit  (Idwii  and  sutured  to  the  anus,  one  should  proceed  to  close 
the  peritontvum  aud  restore  the  planes  of  the  pelvic  Hoor  down  to  the 
levator  ani  bv  tine  catgut  sutures.  After  this  has  been  accomplished  the 
anus,  which  is  now  well  outside  of  the  operative  field,  should  be  reopened, 


Fig.  ■j.'>'^. —  I'hiiiNKAi.  hxTiiii'ATiox. 
P,  lateral  peritoueal  folds;   \\  glandular  eulargeiiieut  between  folds  of  mesorectum. 

the  gauze  should  be  removed,  and  the  gut  flushed  with  a  solution  of 
bichloride  of  mercury  or  peroxide  of  In'drogen.  It  is  then  amputated 
through  healthy  tissue  above  the  tumor,  and  its  upper  end  sutured  at 
the  original  site  of  the  anus.  Quenu  advises  that  in  amputating,  each 
layer  should  be  cut  separately  in  order  to  avoid  haemorrhage,  but  there 
appears  to  be  no  advantage  in  this;  in  fact,  we  are  much  more  likely 
to  meet  with  deficient  blood  supply,  causing  subsequent  sloughing  of 
the  gut,  than  with  haemorrhage.  The  posterior  and  anterior  portions 
of  the  perineal  wound  are  packed  with  gauze  and  left  open  to  assure 
drainage  (Fig.  2G9),  and  the  parts  are  covered  with  aseptic  pads  held 
in  position  by  a  well-fitting  diaper  or  broad  T-bandage.  A  large  drainage- 
tube  is  passed  well  up  into  the  rectum,  its  lower  end  extending  outside 
of  the  dressings  in  order  to  convey  the  discharges  and  gases  beyond  the 
operative  wound.  This  procedure  is  applicable  in  the  female,  but  it 
is  somewhat  difficult  to  avoid  wounding  the  vagina,  and  there  is  always 
danger  of  infection  from  this  organ  during  and  after  the  operation.    It 


EXTIRPATION   OF   THE   RECTUM 


821 


does  not  appear  to  possess  any  advantages  in  women  over  the  vaginal 
route. 

In  incising  the  periton^emn,  it  is  the  author's  practice  to  begin  at 
the  lowest  portion  of  the  anterior  cul-de-sac  and  cut  close  to  the  in- 
testine up  to  the  mesorectum.  From  this  point  upward  he  incises  the 
peritoneal  fold  as  close  to  the  sacrum  as  possible;  first,  because  it 
avoids  the  danger  of  wounding  the  superior  hsemorrhoidal  artery,  and, 
second,  because  it  removes  along  with  the  growth  all  glandular  enlarge- 
ments in  the  mesorectum.  As  can  be  well  understood,  the  operation 
is  not  applicable  to  those  cases  in  which  the  tumor  is  isolated  well 
above  the  rectum,  and  can  be  resected,  leaving  a  healthy  area  of  2  inches 
or  more  between  the  anus  and  the  growth.  In  other  words,  where  resec- 
tion is  feasible,  the  perineal  route  is  not  to  be  advised;  where  amputa- 


FiG.  269. — PEEI^^:AL  Extirpation  Completed. 
U,  tampon  and  drainage-tube  in  anus. 


tion  is  necessary,  this  route  should  be  employed.     The  author  has  suc- 
cessfully removed  5  inches  of  the  gut  by  this  method. 

Saceal  Method:  Kraske's  Opeeatiox. — These  terms  are  applied 
to  various  operations  in  which  access  to  the  rectum  is  obtained  by  re- 
moving the  coccyx  or  cutting  off  certain  portions  of  the  lower  end  of 
the  sacrum.  They  are  all  modifications  of  Kraske's  original  method. 
In  some  the  coccyx  and  parts  of  the  sacrum  are  removed  altogether,  in 


822  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

others  they  are  left  in  the  ilap,  and  restored  to  their  normal  position 
after  the  operation  is  completed. 

Kraske  removed  the  coccyx  and  left  lower  angle  of  the  sacrum  (Fig. 
270);  liocheuegg  the  lower  end  of  the  bone  by  an  oblique  section  extend- 
ing from  the  third  sacral  foramen  on  the  left  to  the  notch  below  the 
fourth  foramen  on  the  right  (Fig.  271);  Bardenheuer  cut  the  bone  square- 
ly across  just  below  the  third  sacral  foramina,  and  removed  all  that  por- 
tion below  this  level  (Fig.  272);  Rose  went  higher  and  removed  all  below 
the  second  foramina  (Fig.  273).  Kraske,  recognizing  that  sufficient 
space  was  not  always  furnished  by  his  original  method,  revised  it  (Ber- 
lin. Idin.  AVoch.,  1888,  No.  48),  and  laid  down  the  guiding  principles  in 
all  these  operations  by  stating  that  only  so  much  of  the  sacrum  should 
be  removed  as  is  necessary  to  reach  all  the  disease,  and  in  many  cases 
excision  of  the  coccyx  alone  will  accomiilish  this.  Senn  (Surgical  Tech- 
nique, Esmarch  and  Kowalzig,  Amer.  edit.,  1901,  p.  821)  limits  himself 
to  this  excision. 

Heinecke,  recognizing  the  disadvantages  of  removing  any  of  the  bony 
floor  of  the  pelvis,  first  proposed  osteoplastic  resection  of  the  coccyx 
and  sacrum  (Miinch.  med.  AVoch.,  1888,  Bd.  xxxvii).  He  made  a  median 
incision  from  the  posterior  border  of  the  anus  to  the  fourth  sacral  fora- 
men, divided  the  coccyx  and  sacrum  longitudinally  with  a  saw,  and  then 
chiseled  the  sacrum  off  transversel}'  below  the  foramina  in  order  to  pre- 
serve the  fourth  sacral  nerves;  he  then  turned  the  flaps  of  bone  and 
soft  tissues  aside  and  thus  exposed  the  rectum  (Fig.  274);  Gussen- 
bauer  followed  the  same  plan,  but  made  the  transverse  cut  just  below 
the  second  sacral  foramina.  Levy  (Centralbl.  f.  Chir.,  1889,  Xo.  13) 
made  a  rectangular  flap,  including  the  bone  and  soft  tissues  below  the 
level  of  tlie  fourth  sacral  foi-amen,  and  dragged  the  flap  downward 
(Fig.  275).  Finally,  Rehn  (Deutsch.  Cong.  f.  Chir.,  1890)  and  Rydygier 
(Centralbl.  f.  Chir.,  1893,  Xo.  1)  pro})osed  the  following  method:  An 
oblique  incision  is  made  through  the  soft  parts  on  the  left  side  of  the 
sacrum  from  the  posterior  superior  spine  of  the  ilium  to  the  tip  of  the 
coccyx,  and  thence  in  a  median  line  to  the  margin  of  the  anus;  a 
transverse  incision  is  then  made  at  the  level  of  the  third  sacral  foramen, 
and  the  bone  chiseled  off  transversely  at  this  point:  the  bone  and  tissue 
flap  thus  formed*is  now  drawn  aside,  exposing  the  posterior  surface  of 
the  rectum  (Fig.  276),  and  extirpation  is  then  carried  out. 

The  author  ado])ts  a  modification  of  this  ])lan  in  preference  to  all 
other  sacral  methods  for  the  following  reasons:  It  furnishes  a  rapid 
and  adequate  approach  to  the  rectum;  it  facilitates  the  control  of  haem- 
orrhage; it  restores  tlie  bony  floor  of  tlie  pelvis  and  attachment  of  the 
anal  mu.scles;  it  involves  injury  of  the  sacral  nerves  and  lateral  sacral 
arteries  on  one  side  only. 


EXTIRPATION  OF  THE  RECTUM 


823 


The  technique  which  he  employs  is  as  follows:  The  patient  is 
previously  prepared  as  heretofore  described,  and  an  artificial  anus 
established  or  not  as  the  conditions  indicate;  before  the  final  scrub- 


Fig.  270.— Kraske's. 


Fig.  273.— Eose's. 


Fig.  271. — Hochenegg's. 


Fig.  272. — Bardenheiier'fe. 


Fio'.  274. — Von  Heiiiecke's. 


Fig.  275. — Levy's. 


Fig.  276. — Eydygier's.  Fig.  277. — Hegar's. 

Figs.  270-277. — Methods  or  Sacral  Eesection  in  Extikpation  of  the  Eectum. 

bing,  the  sphincter  should  be  dilated  and  the  rectum  irrigated  with 
bichloride  solution  (1  to  3,000)  or  peroxide  of  hydrogen;  it  should  then 
be  packed  with  absorbent  gauze  so  that  the  finger  can  not  be  intro- 


S^4i 


THE  ANUS,   RECTUM,  AND   PELVIC   COLON 


ducecl  into  it;  the  patient  is  then  placed  in  the  prone  position  on  the 
left  side,  with  the  hij^s  elevated  on  a  hard  pillow  or  sand-bag;  after  the 
operative  field  has  been  thoroughly  cleansed  an  oblique  incision  is  made 
from  the  level  of  the  third  foramen  on  the  right  side  of  the  sacrum 
down  to  the  tip  of  the  coccyx,  and  extended  half-way  between  this  point 
and  the  posterior  margin  of  the  anus.  This  incision  should  be  made 
boldly  with  one  stroke  through  the  skin  muscles  and  ligaments  into 
the  cellular  tissue  posterior  to  the  rectum;  the  latter  is  rapidly  separated 
by  the  fingers  from  the  sacrum,  and  the  space  thus  formed,  together 
with  the  wound,  should  be  firmly  packed  with  sterilized  gauze  (Fig.  278); 


ilG. 


;?'>. — EXTIRI'ATIUX    oi'    THE    KErTlM    BY   THE    SaCRAL    KoUTE— FiRST    .StEP    IX    THE    lioNE- 
FLAP    OpEEATION. 


a  transverse  incision  down  to  the  bone  is  then  made  at  the  level  of  the 
fourth  sacral  foramen,  the  bone  is  rapidly  chiseled  off  in  this  line,  and 
the  triangular  flap  is  pulled  down  to  the  left  side,  where  it  is  held  by 
the  weight  of  a  heavy  retractor  attached  to  it.  At  this  point  it  is  usually 
necessary  to  catch  and  tie  the  right  lateral  and  middle  sacral  arteries. 
Frequently  these  are  the  only  vessels  that  need  be  tied  during  the 
entire  operation  of  resection,  although,  if  one  cuts  too  far  away  from 
the  sacrum,  the  right  sciatic  artery  may  be  severed.  The  relations  of  the 
parts  thus  exposed  are  well  shown  in  the  cut  (Fig.  279),  made  from  a 
very  old  picture  lent  to  the  author  by  Dr.  A.  T.  Cabot,  of  Boston. 


\*«» 


Fig.  279. — Sacrum  removed  to  expose  Eectum  and  othee  Pelvic  Organs  (partly  schematic). 

A,  superior  hsemorrhoidal  artery ;   B,  vas  deferens ;    C,  ureter ;   D.  lateral  sacral  artery ; 
E,  seminal  vesicles ;   F,  rectum ;    G,  bladder.     (Cabot.) 


•826 


THE  ANUS,   RECTUM.  AND   PELVIC  COLON 


The  first  step  in  the  actual  extirpation  of  the  rectum  consists  in 
isolating  the  organ  below  the  level  of  the  resected  sacrum  so  that  a  liga- 
ture can  be  thrown  around  it,  or  a  long  clamp  applied  to  control  any- 
bleeding  from  its  walls  (Fig.  280).     If  the  neoplasm  extends  above  this 


Fig.  250. — Second  .Step  ix  Boxe  flap  Operation. 
R,  rectum ;   N,  neoplasm  ,  L  S,  lateral  rectal  ligaments  ;  ,S,  sacrum. 


level  and  it  is  necessary  to  open  the  peritoneal  cavity  to  extirpate  it,  one 
should  do  this  at  once,  as  it  will  be  found  much  easier  to  dissect  the  rec- 
tum out  by  following  the  course  of  the  peritoneal  folds.  By  opening  the 
peritoneum  and  incising  its  lateral  folds  close  to  the  rectum  (Fig.  281), 
the  danger  of  wounding  the  ureters  is  greatly  decreased  and  the  gut  is 
much  more  easily  dragged  down.  When  the  posterior  peritoneal  folds  or 
mesorectum  is  reached,  the  incision  should  be  carried  as  far  away  from 
the  rectum,  or  rather  as  close  to  the  sacrum,  as  possible  in  order  to  avoid 
wounding  the  superior  hemorrhoidal  artery,  and  to  remove  all  the  sacral 
glands.  The  gut  should  be  loosened  and  dragged  down  until  its  healthy 
portion  easily  reaches  the  anus  or  the  healthy  segment  below  the  growth 
(Fig.  282).  A  rubber  ligature  or  strong  clamp  should  then  be  placed  upon 
the  intestine  about  1  inch  above  the  neoplasm,  but  i^hould  never  be  placed 
in  the  area  involved  bv  it,  for  in  so  doing  the  friable  walls  may  rupture 
and  the  contents  of  the  intestine  be  poured  out  into  the  wound.     As 


EXTIRPATION  OF   THE  RECTUM 


827 


soon  as  the  gut  has  been  sufficiently  liberated  and  dragged  down,  the 
peritoneal  cavity  should  be  cleansed  by  wiping  with  dry  sterilized  gauze, 
and  then  closed  by  sutures  which  attach  the  membrane  to  the  gut  (Fig. 
282,  P).  By  this  procedure  the  entire  intraperitoneal  part  of  the  opera- 
tion is  completed  and  this  cavity  closed  before  the  intestine  is  incised. 
After  this  is  done  the  gut  should  be  cut  across  between  two  clamps  or  lig- 
atures above  the  tumor,  the  ends  being  cauterized  with  carbolic  acid,  and 
covered  with  rubber  protective  tissue.  The  lower  segment  containing 
the  neoplasm  may  then  be  dissected  from  above  downward  in  an  almost 
bloodless  manner  until  the  lowest  portion  is  reached.  It  is  much  more 
easily  removed  in  this  direction  than  from  below  upward,  and  there  is 
less  danger  of  wounding  the  other  pelvic  organs.  If  the  neoplasm  ex- 
tends within  1  inch  of  the  anus  it  will  be  necessary  to  remove  the 
entire  lower  portion  of  the  rectum.  If,  however,  more  than  1  inch 
of  perfectly  healthy  tissue  remains  below,  this  should  always  be  pre- 


FiG.  281. — Third  Step  i.\  Boxe-flap  ()rij:Aii"N. 
P,  opening  in  the  peritoiiffiuni ;   I',  seminal  vesicle  and  bladder ;  N,  neoplasm  ;  B,  rectum. 


served.  Having  removed  all  of  the  neoplasm,  if  1  inch  or  more  of 
healthy  gut  remains  above  the  anus,  one  should  unite  the  proximal 
and  distal  ends  of  the  gut  either  by  the  Murphy  button  or  end-to-end 
suture  (Fig.  283).    The  author  has  applied  both  methods  about  an  equal 


828 


THE   ANUS,  RECTUM,   AND   PELVIC  COLON 


inimber  of  times,    lie  is  of  the  opinion  that  through-and-througii  suture 
of  the  intestine  is  quite  as  satisfactory  as  any  other  method.     Posterior 


Flu.   'J-  J,      I  '  ii  i:  I  M    >  n.i'   IN    I!'  .Ni.  I  I  \  I'   <  I  I'll;  M  Ion. 
i?,  rectum  ;  .Si,  ^iiguioid  ;  A',  site  of  recto-vesical  cul-de-sac ;  P,  peritoneal  cavity  closed. 

fistuhi  follows  in  almost  every  case,  but  it  generally  heals  spontaneously, 
and  need  give  no  serious  concern. 

Where  there  is  less  than  1  inch  of  the  rectum  left  below,  and  the 
gut  can  be  easily  brought  down  to  the  anus,  it  is  well  to  dissect  off 
the  mucous  membrane  from  the  latter  organ,  invaginate  the  upper  end 
of  the  intestine  through  this,  and  suture  it  to  the  skin  outside.  The 
gut  is  not  sutured  to  the  margin  of  the  anus,  but  entirely  ouside  of 
it,  in  order  that  the  faecal  passages  will  not  come  in  contact  with  the 
line  of  union  between  the  freshened  portion  of  the  anus  and  the 
peritoneal  surface  of  the  gut  which  has  been  dragged  down.  No 
tension  should  be  employed  in  bringing  the  gut  down  to  position.  After 
it  has  been  fixed  in  place,  a  large  silk  anchoring  suture  is  placed 
in  the  mesorectum  about  3  inches  above  the  anus  and  attached  to  the 
skin  outside  the  lower  angle  of  the  wound,  in  order  to  prevent  retraction 
of  the  gut  and  tension  on  the  sutures.  In  some  instances  in  which,  con- 
trary to  expectations  before  the  operation,  we  are  unable  to  reunite  the 
ends  of  the  intestine  or  to  bring  the  proximal  end  down  to  the  anus,  it 
is  necessary  to  attach  the  latter  at  a  higher  level  in  the  wound,  thus 


EXTIRPATION   OF  THE   RECTUM 


829 


forming  what  is  known  as  a  sacral  amis  (Fig.  2S4:).  All  oozing  is  checked 
by  hot  compresses,  and  the  concavity  of  the  sacrum  is  packed  with  a  large 
mass  of  sterilized  gauze,  the  end  of  which  protrudes  from  the  lower 
angle  of  the  wound;  this  serves  to  check  any  oozing  and  also  furnishes 
a  support  to  the  bone-flap  after  it  has  been  restored  to  position.  Finally, 
the  flap  is  fastened  back  in  its  original  position  by  silkworm-gut  sutures, 
which  pass  deeply  through  the  skin  and  periosteum  on  each  side  of  the 
transverse  incision.  Suturing  the  bone  itself  is  not  necessary.  The 
lateral  portion  of  the  wound  is  closed  by  similar  sutures  down  to  the  level 
of  the  sacro-coceygeal  articulation;  below  this  it  is  left  open  for  drainage 
(Fig.  285).  A  large  drainage-tube  is  carried  up  through  the  gut  beyond 
the  line  of  intestinal  sutures,  and  the  whole  is  dressed  with  sterilized 
absorbent  gauze  held  in  position  by  adhesive  straps  and  a  firm  J-bandage. 
The  patient  is  placed  in  bed,  lying  upon  the  back  or  right  side,  and  the 
head  of  the  bed  is  slightly  elevated  in  order  to  prevent  any  concealed 
haemorrhage  escaping  upward  into  the  peritoneal  cavity.    It  is  important 


ri&.  283. — ^FiFTH  Step  in  Bose-flap  Operation. 
The  growtli  has  been  resected  and  the  ends  of  the  intestine  have  been  sutured  together. 


that  the  surgeon  should  know  exactly  how  much  oozing  is  taking  place 
from  the  wound;  the  decrease  in  oozing  accomplished  by  raising  the  foot 
of  the  bed  does  not  compensate  for  the  dangers  of  concealed  bleeding. 


830 


THE  ANUS,   RECTUM,  AND  PELVIC  COLON 


Usually  there  is  considerable  oozing  lor  the  hrst  twenty-i'our  hours 
following  the  operation,  during  which  time  the  outside  dressings  should 
be  replaced  by  fresh  ones  several  times,  the  inner  dressing  being  left 
in  situ  for  seventy-two  hours.  After  this  they  are  removed,  and  either 
drainage-tubes  or  small  gauze  strips  introduced  into  the  hollow  of  the 
sacrum.  The  patient  is  encouraged  to  get  upon  his  feet  as  soon  as 
possible  in  order  that  the  parts  may  drain  more  easily,  and  that  the 
weight  of  the  abdominal  contents  will  press  the  pelvic  floor  backward 
in  contact  with  the  sacrum,  and  thus  hasten  the  filling  in  of  this  cavity. 

The  patient  is  kept  upon  concentrated  liquid  diet,  and  if  a  prelimi- 
nary artificial  anus  has  not  been  employed  his  bowels  should  be  confined 
by  opium  for  the  first  ten  days,  after  which  they  are  moved  by  enemata 
of  oil  and  glycerin. 

This  technique  has  now  been  employed  for  six  years;  it  differs  from 
that  of  Eehn  and  Rydygier  in  the  following  points:  First,  the  incision  is 


Fig.  284. — Saoral  Anus. 
Made  in  bone-flap  operation  wlien  it  was  impossible  to  establish  aperture  in  normal  position. 


made  upon  the  right  side  of  the  sacrum  because  it  is  much  more  con- 
venient to  operate  from  this  side,  the  bone-flap  falls  out  of  the  way 
through  gravitation,  and  because  the  rectum  is  slightly  nearer  the  right 
side  of  the  sacrum  at  its  lower  end;  second,  the  peritoneal  portion  of 


EXTIRPATION  OP   THE  RECTUM 


831 


the  operation  is  completed  and  the  cavity  closed  before  the  gut  is 
opened  at  all;  third,  the  extirpation  of  the  rectum  itself  is  made  from 
above  downward,  in  which  line  the  cleavage  of  the  parts  is  much  more 
easily  determined  than  from  below  upward;  fourth,  the  haemorrhage  is 


Fig.  285. — Final  Step  in  Bune-flap  Operation. 
G,  gauze  draining  retro-rectal  space ;  T,  tampon  and  drainage-tube  in  anus. 

practically  controlled  by  tying  oi?  the  middle  and  lateral  sacral  arteries 
in  the  beginning,  and  clamping  the  superior  hsemorrhoidal  artery  before 
the  lower  dissection  is  made.  The  avithor  does  not  mean  to  claim  any 
originality  by  pointing  out  these  distinctions,  but  simply  to  impress 
upon  the  reader  the  points  in  which  he  has  found  it  advisable  to  modify 
the  original  Eehn-Eydygier  technique. 

The  objections  urged  against  this  operation  are  that  the  bone  does 
not  reunite,  and  necrosis  is  likely  to  occur.  The  author  has  not  seen 
a  single  case  of  necrosis  follow  the  bone-flap  operation,  and  in  every 
case  in  which  he  has  employed  it  the  bone  has  reunited  in  fairly  accurate 
position.  In  two  or  three  cases  suppurating  sinuses  through  the  trans- 
verse incision  have  developed,  but  they  have  invariably  healed  without 
secondary  operation.  Some  operators  do  not  suture  the  flap  back  in 
position,  and  claim  that  to  leave  the  entire  wound  open  furnishes  better 
drainage  and  affords  a  safeguard  against  sepsis.  It  appears,  however, 
that  the  long,  oblique  opening  below  is  sufficient  for  this,  and  that 


832 


THE  ANCS,   RECTUM,  AND  PELVIC  COLON 


suturing  the  boucs  in  position  accomplishes  a  more  accurate  restoration 
of  the  parts  and  quicker  healing. 

The  other  modifications  of  Kraske's  operation  consist  simply  in  dif- 
ferent incisions  of  the  soft  parts  and  treatments  of  the  bones  as  is 

seen  in  the  illustra- 
tions (Figs.  269  to 
276).  The  technique 
of  removing  the  rec- 
tum after  it  is  exposed 
is  the  same  in  all. 
The}'  possess  no  ad- 
vantages over  the 
l)one-flap  method  dur- 
ing the  operation,  and 
leave  a  gap  in  the  pel- 
vic floor  which  is,  to 
say  the  least,  undesir- 
able. The  author  no 
longer  employs  these 
methods,  and  will  not 
describe  them  in  de- 
tail. 

The  V  a  g I X  a  l 
Method.  —  Extirpa- 
tion of  cancer  of  the 
rectum  through  the 
vagina  was  first  done  by 
Desguins  (Annales  de 
la  soeiete  de  med.,d'An- 
vers,  1890)  in  a  case  in 
which  the  recto-vaginal 
sfeptum  was  involved. 
The  steps  of  this  original  operation  are  not  very  clearly  described, 
but  it  appears  to  have  been  a  perinaeo-vaginal  procedure,  with  con- 
servation of  the  sphincters.  The  patient  died,  but  the  cause  of  death 
was  not  stated.  Xorton  (Trans.  Clin.  Soc,  London,  1890)  performed 
the  operation  in  the  same  year,  excising  the  entire  lower  segment  of 
the  gut,  including  the  sphincter,  and  suturing  the  bowel  to  the  skin. 
This  patient  made  a  good  recovery,  and  had  faecal  control  within  a 
short  time  after  the  operation.  Campenon  (Union  medical,  October, 
1891),  Rehn  (Centralbl.  f.  Chir.,  Berlin,  1895,  S.  2U),  Yautrin  (Gaz. 
hebdom.  de  med.  et  de  chir.,  1896,  p.  283),  Price  (Med.  and  Surg.  Re- 
porter, 1896,  p.  66),  Bristow  (Med.  News,  1896,  p.  40),  Bjiord  (Annals 


Fig.  i:^''.,  —  Ke'Ial  (.'aU'INhma  involvin 


>IXAI,    W 


EXTIRPATION   OF   THE  RECTUM 


833 


of  Surgery,  1896,  p.  G31),  and  Earle  (Proc.  Am.  Proctologic  Soc,  1899) 
have  adopted  this  method  with  various  degrees  of  success.  Gersuny 
employed  it  in  14  cases  with  only  2  operative  deaths  (Sternberg,  Cen- 
tralbl.  f.  Chir.,  1897,  S.  305). 

More  recently  ]\Iurphy,  of  Chicago,  has  reviewed  this  subject  in  detail, 
and  reported  5  successful  cases.  Up  to  1897  most  operators  confined 
this  method  to  tumors  in  the  middle  and  lower  portions  of  the  rectum, 
but  with  the  development  of  the  vaginal  method  in  gyntecological  opera- 
tions, it  became  more  and  more  apparent  that  even  the  ujjpermost  portion 
of  the  sigmoid  flexure  could  be  reached  and  extirpated  by  this  route. 
The  method  is  therefore  no  longer  limited  to  the  rectum,  but  is  even 
advocated  in  carcino- 
ma of  the  lower  loops 
of  the  sigmoid.  The 
technique  of  the  oper- 
ation, as  laid  down  by 
Murphy,  is  as  follows: 

The  patient  is 
placed  in  the  lithot- 
omy position,  with  the 
hips  slightly  elevated. 
The  site  of  the  tumor 
determines  whether  the 
peritonaeum  should  be 
opened  or  not  (Fig. 
286).  The  vagina  is 
dilated  with  broad 
retractors,  the  cervix 
drawn  down,  and  Doug- 
las's cul-de-sac  opened 
by  a  transverse  inci- 
sion just  below  the 
cervical  juncture.  The 
small  intestines  are 
then  pushed  upward 
out  of  the  way,  and 
the  peritoneal  cavity 
is  packed  with  large 
laparotomy  sponges  or 


Fig.  287. — Incisiok  in  Vaginal  Extirpation  (Murphy). 


pads,  a  careful  count  being  kept  of  the  number  used.  The  reeto-vaginal 
sfeptum  is  then  divided  by  a  vertical  incision  in  the  median  line,  extend- 
ing from  the  first  incision  down  to  the  margin  of  the  anus,  and  including 
the  external  sphincter  (Fig.  287).  The  vaginal  wall  is  then  dissected 
53 


83tl: 


THE  AXUS,  RECTUM,   AND  PELVIC   COLON 


from  its  attaelimeuts  to  the  reetuiii,  thus  exposing  this  organ  iu  its  en- 
tire length  and  enabling  one  to  examine  it  and  drag  down  the  sigmoid 
flexure  almost  at  will  (Fig.  288).     At  this  point  Murphy  divides  the 

anterior  rectal  wall  up 
to  the  lower  border  of  • 
the  tumor,  and  incises 
the  gut  transversely  1 
inch  below  the  lower 
limits  of  the  growth, 
carrying  the  incision 
into  the  retro-rectal 
tissue  (Fig.  289).  The 
proximal  end  of  the  gut 
is  then  grasped  with 
forceps,  which  close  it, 
and  by  the  use  of  curved 
scissors  it  is  separated 
from  its  posterior  at- 
tachments as  far  as  the 
promontory  of  the  sa- 
crum, or  at  least  suffi- 
ciently far  for  the 
l:)Owel  to  be  drawn  down 
until  its  healthy  por- 
tion reaches  the  lower 
segment  without  undue 
tension.  The  gut  is 
then  amputated  above 
the  growth  (Fig.  290), 
and  the  upper  and  low- 
er segments  are  united 
end  to  end  by  silkworm 
sutures.  These  sutures  should  be  passed  from  without  inward,  the  knots 
being  tied  upon  the  inside,  and  the  ends  left  long  to  facilitate  their 
removal.  The  wound  in  the  anterior  wall  of  the  rectum  is  closed  in  the 
same  manner,  and  the  ends  of  the  sphincter  brought  together  by  buried 
catgut  sutures  (Fig.  291).  After  the  laparotomy  pads  are  removed,  the 
peritoneal  wound  is  closed  with  a  continuous  catgut  suture,  and  the 
vaginal  wound  is  brought  together  with  silkworm-gut  sutures  (Fig.  292). 
A  large  drainage-tube  is  introduced  through  the  anus  above  the  point 
of  anastomosis  and  sutured  in  position,  the  vagina  and  external  parts 
being  dressed  with  sterilized  gauze.  Murphy  does  not  advise  preliminary 
colostomy,  and  it  is  difficult  to  understand  how  he  can  avoid  a  certain 


Fig.  2s6. — "Sti-AKATioN  of  Kectuji  from  Vaginal  Walls 
( Murphy  j. 


EXTIRPATION  OF   THE   RECTUM 


835 


amount  of  iiiffcliou  in  this  operation,  as  the  gut  is  cut  across  and 
opened  in  the  operative  field  before  the  peritonaeum  is  closed.  This  and 
the  fact  that  a  large  space  is  necessarily  left  in  the  hoUo-n-  of  the  sacrum 
on  account  of  the  removal  of  the  cellular  mass  in  which  the  glands  are 
found,  renders  it  very  important  that  adequate  drainage  for  this  cavity 
should  be  furnished.  The  author  therefore  varies  Murphy's  technique 
by  commencing  the  operation  with  a  semicircular  incision  between 
the  anus  and  coccyx,  and  extending  into  the  retro-rectal  space.  "With 
the  fingers  or  a  dull  instrument  the  cellular  tissues  and  rectum  are 
separated  from  the  anterior  surface  of  the  sacrum  and  coccyx  as 
high  up  as  the  growth  extends.  After  this  has  been  accomplished, 
the  wound  and  sacral 
concavity  are  packed 
with  iodoform  gauze 
to  control  the  oozing, 
and  the  vaginal  por- 
tion of  the  operation 
is  then  conducted  ac- 
cording to  ^Murphy's 
technique,  with  the  ex- 
ception that  the  gut  is 
not  cut  across  until  it 
has  been  freed  from 
all  its  attachments. 
dragged  down  as  far 
as  is  necessary,  and  the 
peritoneal  cavity  closed 
by  sutures  or  firm  pack- 
ing. The  post-anal 
wound  and  loosening 
of  the  retro-rectal  tis- 
sues not  only  furnishes 
adequate  drainage  in 
case  of  leakage,  but  it 
facilitates  the  dissect- 
ing out  of  the  rectum 
and  saves  time  in  the 
operation.  The  use  of 
silkworm-gut  sutures  in 
the  intestinal  wall  ne- 
cessitates their  removal,  usually  under  anaesthesia;  on  the  other  hand, 
ten-dav  chromicized  catgut  serves  every  purpose,  and  does  not  re- 
quire to  be  removed.     AVith   these  few  modifications,  the  author  be- 


FiG.  269.- 


-EECmi   LAID    OPEX    AXD    CUT   ACROSS    BELOW 

Xeoplasm  (ilurphy). 


836 


THE   AXUS,  RECTUM,  AND  PELVIC  COLON 


lievcs  this  tcc-lmi(jiu'  di'  .Mui'iihy  to  he  a  most  useful  addition  to  rectal 
surgery. 

On  the  whole,  however,  except  in  cases  where  the  vaginal  wall  or 
the  uterus  is  involved,  there  is  no  great  advantage  in  the  vaginal  route 
over  the  perineal  and  bone-flap  operations  described  above.  It  requires 
more  time,  there  is  greater  loss  of  blood,  and  there  is  more  danger  of 
infection  through  uterine  discharges  and  dribbling  of  urine  than  in  the 
sacral  operation.  Surgical  shock  is  somewhat  greater  in  the  sacral 
than  it  is  in  the  perineal  or  vaginal  operations,  but  this  is  more  than 
compensated  by  the  diminished  loss  of  blood.     The  results  thus  far 

reported  are  entirely 
favorable  to  the  vag- 
inal route,  but  the 
number  of  operations 
is  not  sufficiently  large 
as  yet  to  justify  its 
universal  adoption. 

Abdomixal  Meth- 
od.— Operations  on  the 
pelvic  organs  with  the 
jiatient  in  the  Tren- 
delenburg position 
early  demonstrated  the 
feasibility  of  removing 
neoplasms  of  the  up- 
])er  rectum  and  sig- 
moid flexure  through 
the  abdominal  route. 
Where  the  tumor  is 
limited  to  that  portion 
of  the  intestinal  tract 
entirely  surrounded  by 
]ieritonjBum,  especially 
where  it  is  in  the  mov- 
able sigmoid  and  can 
be  drawn  out  of  the 
abdominal  wound,  this 
method  is  undoubtedly 
superior  to  all  others. 
It  involves  no  great  mutilation  of  tissues,  and  the  excision  can  be 
quickly  executed  by  the  aid  of  a  Murphy  button  or  O'Hara  clamp. 
Where  the  tumor  is  well  below  the  promontory  of  the  sacrum,  how- 
ever,  in   that   portion   of   the   gut   only   partially   covered   by   perito- 


FiG.  290. — Eesectiox  of  Involved  Ap.ea  in   \'a<;ixal 
Extirpation"  of  the  Kectimi  (Murphy;. 


EXTIRPATION   OF   THE   RECTUM 


837 


na?um^  comjolete  removal  by  this  route  alone  is  attended  with  many 
difficulties. 

Mann,  of  Buffalo  (Jour,  of  the  Amer.  Med.  Ass'n,  vol.  ii,  p.  23), 
has  recently  advocated  the  method  even  in  these  latter  cases.  He  states 
that  by  the  aid  of  the 
Murphy  button  end-to- 
end  union  can  be  ob- 
tained even  in  that  por- 
tion of  the  intestine 
well  below  the  perito- 
neal cul-de-sac.  His  ex- 
perience (3  cases  with 
1  death)  is  too  limited 
to  warrant  any  conclu- 
sions with  regard  to 
the  operation.  Murphy ' 
himself,  Marcy,  and 
the  author  have  applied 
the  button  in  cases 
where  there  was  no 
peritoneal  covering  on 
one  segment  of  the  gut, 
and  almost  invariably 
leakage  and  a  fistula 
have  followed.  In  the 
sacral  operation,  where 
there  is  wide  drainage 
below,  this  has  not  re- 
sulted in  any  serious 
consequences.  In  an 
abdominal  operation, 
however,  in  which  there 
is  no  dependent  drain- 
age, such  an  accident  as  this  will  almost  certainly  prove  fatal.  End-to- 
end  suturing  of  the  gut  deep  down  in  the  pelvic  cavity  is  one  of  the 
most  difficult  procedures,  as  the  author  can  testify  from  three  attempts, 
in  two  of  which  he  was  compelled  to  abandon  it  and  emjDloy  another 
method.  In  his  opinion,  therefore,  the  abdominal  method  should  be 
limited  to  those  cases  in  which  the  neoplasm  is  entirely  within  the 
peritoneal  portion  of  the  intestine . 

As  early  as  1895  Kelly  resected  the  upper  portion  of  the  rectum 
and  a  part  of  the  sigmoid,  and  invaginated  the  proximal  end  of  the  latter 
through  a  longitudinal  slit  in  the  anterior  wall  of  the  rectum  in  Doug- 


FiG.  ■J.'A. — Eestoratiox  of  Gut  ix   \'aij1-\al  Extikpatiok 
OF  THE  EECTUii  (Murpliy). 


838 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


las's  cul-de-sac;  thus  the  peritoneal  surface  of  the  sigmoid  was  held  ia 
contact  with  a  comparatively  wide  surface  of  the  peritoneum  covering 

the  rectum.  The  up- 
per end  of  the  resected 
rectum  was  invaginat- 
ed  and  closed  by  Lam- 
bert sutures. 

Following  his  sug- 
gestion, the  author  has 
employed  this  method 
three  times,  twice  in 
resection  of  the  sig- 
moid and  upper  rec- 
tum for  carcinoma  and 
once  in  entero-anasto- 
mosis  for  irremovable 
cancer  of  the  sigmoid. 
The  first  of  these  op- 
erations was  done  in 
March,  1896.  The  pa- 
tient was  suffering 
from  carcinoma  of  the 
last  loop  of  the  sigmoid 
9  inches  above  the 
anus.  An  oblique  ab- 
dominal incision  4 
inches  in  length  was 
made  about  1  inch  in- 
side of  the  ordinary  in- 
cision for  colostomy. 
After  the  peritoneal 
cavity  had  been  opened,  the  patient  was  placed  in  the- Trendelen- 
burg posture,  and  the  small  intestines  and  omentum  were  forced 
upward  toward  the  diaphragm  and  held  there  by  large  abdominal 
pads.  The  tumor  was  isolated  by  incising  the  mesosigmoid  down  to  a 
point  about  opposite  the  second  sacral  vertebra,  where  the  gut  ap- 
peared to  be  healthy.  Two  ligatures  were  thrown  about  the  intestine 
at  this  point,  and  it  was  cut  transversely  between  them,  gauze  being 
packed  all  around  the  parts  in  order  to  prevent  soiling  the  peritonaeum 
with  intestinal  contents.  The  upper  segment  was  drawn  out  of  the 
abdominal  wound,  cauterized  with  carbolic  acid,  and  covered  with  pro- 
tective tissue.  Without  removing  the  gauze  packing,  the  lower  segment 
was  similarly  cauterized,  its  edges  invaginated,  and  closed  by  Lembert 


Fig.  292. — Closure  of  Peritoneum  and  Vaginal  Wound 
AFTER  Vaginal  Extirpation  of  the  Kectum  (Murphy). 


EXTIRPATION  OF   THE  RECTUM 


839 


sutures;  after  this  the  gauze  packing  was  removed  and  the  cut  edges 
of  peritonaeum  composing  the  mesentery  were  drawn  together  with  fine 
silk  sutures.  Tlie  segment  of  the  gut  containing  tlie  carcinoma  was  then 
excised,  a  stout  ligature  having  been  placed  around  the  intestine  about 
1  inch  above  the  transverse  section.  The  mucous  membrane  of  the 
upper  segment  was  then  cauterized  with  pure  carbolic  acid  and  dried 
with  gauze,  i^fter  this  four  long  sutures  were  placed  equidistant  in 
its  circumference,  the  ends  of  each  being  tied  together  so  as  to  form 
a  loop.  An  incision  of  about  1-J  inch  was  then  made  in  the  anterior 
wall  of  the  rectum  through  the  peritoneal  cul-de-sac  after  the  sphincter 
had  been  stretched  and  the  anus  thoroughly  irrigated.  A  long  for- 
ceps was  then  introduced 
through  the  anus  and 
through  this  incision,  by 
which  the  loops  in  the 
proximal  end  of  the 
gut  were  grasped  and 
brought  out  below. 
These  loops  were  thor- 
oughly twisted  together 
so  as  to  narrow  the 
aperture  of  the  gut  be- 
fore any  traction  was 
made  upon  it.  After 
this  the  sigmoid  was 
dragged  downward  and 
invaginated  through  the 
incision  in  the  anterior 
wall  of  the  rectum  (Fig. 
293).  When  the  end  of 
the  upper  segment  had 
passed  through  the  in- 
cision the  ligature  sur- 
rounding the  intestine 
was  cut  off.  The  long 
sutures  attached  to  the 
intestine  were  wrapped 
around  a  haemostatic 
forceps,  which  was  twist- 
ed until  they  held  the  bowel  comparatively  taut,  and  this  was  al- 
lowed to  lie  across  the  anus  as  a  sort  of  windlass.  A  gauze  drain 
was  carried  down  to  the  point  of  invagination  and  out  through  the 
lower  angle  of  the  abdominal  wound,  which  was  then  closed  except 


Fig.  293. — Colorectostojiy  (Kelly)  or  Ixvaginatiok  of 
Colon  through  a  Slit  in  the  Anterior  Wall  of 

THE    KecTUM. 


840 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


at  this  point.  Tlie  healing  of  the  parts  was  uneventful,  hut  at  the  end 
of  one  month  it  was  apparent  that  the  caliher  of  the  gut  at  the  point 
of  invagination  was  entirely  too  narrow.  In  order  to  overcome  this 
tlie  patient  was  placed  in  the  Trendelenburg  posture  and  a  hysterectomy 
clamp  was  passed  upward  through  the  anus,  one  blade  of  it  being  car- 
ried through  the  narrowed  orifice  into  the  sigmoid  and  the  other  into 
the  upper  segment  of  the  closed  rectum  (Fig.  294).  The  clamp,  being 
closed  and  tightened  daily,  cut  its  way  through  in  five  days,  thus  mate- 
rially widening  the  caliber  of  the  gut.  From  that  time  forward  the 
patient's  symptoms  continued   to   improve.     He  gained   in  flesh   and 

strength,  and  up 
to  Aprd,  1903,  had 
presented  no  signs 
of  recurrence.  The 
cul-de-sac  formed 
by  the  closing  of 
the  upper  end  of 
the  rectum  gradu- 
ally atrophied  and 
apparently  disap- 
l)cared  (Fig.  295). 
At  the  last  exam- 
ination a  sigmoid- 
oscope of  25  milli- 
meters in  diameter 
was  passed  into  the 
sigmoid  flexure 
without  any  diffi- 
culty. In  the  other 
cases  of  resection 
in  which  this  meth- 
od was  employed 
no  drainage  was 
used,  and  the  ab- 
dominal cavity  was 
closed  on  complet- 
ing the  operation. 
A  longer  incision 
was  made  in  the 
rectum  in  one  instance,  and  it  was  not  necessary  to  afterward  enlarge  the 
opening  in  the  gut  at  the  point  of  juncture.  This  patient  was  observed 
for  two  years,  and  remained  well  during  that  period.  He  disappeared, 
however,  and  has  not  been  heard  from  in  the  past  eighteen  months. 


Fig.  294.— Method  of  widening  the  Caliber  of  the  Gut  after 

CoLORECTOSTOilY. 


EXTIRPATION  OF   THE  RECTUM 


841 


"Where  the  tumor  is  low  down  in  the  sigmoid  and  j^et  can  be  removed^ 
at  the  same  time  j^reserving  the  anterior  wall  of  the  rectum,  it  appears 
to  the  author  that  this  method  is  superior  to  attempts  at  end-to-end 
union,  inasmuch  as  there  is  a  wide  apposition  of  the  peritoneal  surfaces 
and  the  proximal  end  of  the  sig- 
moid is  carried  well  within  the 
rectum,  thus  avoiding  any  great 
danger  from  leakage  and  peri- 
tonitis. 

"Where  the  tumor  is  confined 
to  the  sigmoid  proper  and  can 
be  brought  outside  of  the  ab- 
dominal wound,  resection  should 
be  made  according  to  the  accept- 
ed methods  of  intestinal  surgery. 
The  author  has  resected  the  sig- 
moid flexure  nine  times,  in  five 
of  which  the  operation  was  done 
for  malignant  growths,  with  one 
fatal  result.  He  has  invariably 
employed  a  Murphy  button  which 
fitted  loosely  in  the  caliber  of 
the  gut,  and  reenforced  it  with 
Lembert  sutures.  "While  he  is 
aware  that  this  is  contrary  to 
the  teachings  of  Murphy  him- 
self, nevertheless  it  appears 
safer  to  have  a  supplemental^ 
guard  against  leakage,  and  from 

his  experience  he  sees  no  reason  to  alter  this  course.  End-to-end 
suturing,  with  or  without  the  aid  of  an  O'Hara  clamp,  may  be  em- 
ployed in  these  cases,  but  it  consumes  more  time  than  the  application 
of  the  Murphy  button,  and  does  not  give  any  better  results. 

The  thought  has  suggested  itself  that  in  carcinoma  of  the  sigmoid, 
in  which  the  tumor  can  be  brought  entirely  outside  of  the  abdominal 
wall,  it  might  be  safer  to  fix  it  in  this  position  until  the  peritoneal 
cavity  is  closed  off  by  adhesions,  and  then  excise  it  extra-abdominally. 
This  would  involve  an  artificial  anus,  to  close  which  finally  it  would  be 
necessary  to  employ  end-to-end  union  of  the  segments,  and  this  might 
be  quite  as  dangerous  as  performing  the  entire  operation  at  one  sitting. 
The  case  which  suggested  this  thought  was  the  fatal  one  in  this  series. 
The  stricture  in  this  instance  was  so  tight  that  it  was  impossible  to 
thoroughly  empty  the  bowel  before  the  operation;  as  a  consequence  of 


Fig.  295. — Kesult  of  Colorectostomy  for 
Carcinoma  as  seen  through  Proctoscope 
Five  Years  after  Operation. 


842  THE  ANUS,   RECTUM,   AND   PELVIC  COLON 

this  there  was  a  large  mass  of  hard  faecal  balls  in  the  colon  above  the 
site  of  the  tumor.  The  gut  was  dragged  outside  of  the  abdominal 
wound  after  it  was  cut  across  above  the  tumor,  and  as  many  of  these 
as  possible  were  removed,  but  unfortunately  one  of  those  high  up  in 
the  transverse  colon  came  down  and  obstructed  the  aperture  in  the  Mur- 
phy button,  thus  causing  obstruction  and  tearing  of  the  gut,  which 
was  followed  by  peritonitis  and  death.  In  such  cases,  therefore,  where 
the  upper  bowel  can  not  be  emptied  before  the  operation,  the  author 
would  advise  either  making  a  temporary  colotomy  until  the  bowel  could 
be  cleaned  out,  and  then  removing  the  neoplasm  at  another  sitting,  or 
the  employment  of  the  extra-abdominal  method  suggested  above.  It  is 
unnecessary  to  go  into  the  details  of  intestinal  resection  as  applied  to 
the  sigmoid  flexure.  This  operation  is  described  in  all  modern  works 
on  general  surgery.  The  author  prefers  the  use  of  the  Murphy  button 
supplemented  by  Lembert  sutures,  but  excellent  results  may  be  obtained 
by  other  methods.  That  the  button  may  be  retained  there  is  no  doubt. 
We  have  failed  to  recover  them  in  6  cases,  but  in  none  of  these  has  it 
seemed  to  do  any  harm.  The  other  complications  which  are  said  to 
follow  its  use  have  not  been  met  with,  and  are  certainly  no  more  fre- 
quent than  those  which  occur  in  end-to-end  union  or  lateral  anastomosis 
by  sutures.  To  conclude  this  subject,  the  abdominal  operation  alone 
should  be  reserved  for  neoplasms  of  the  pelvic  colon  as  defined  in  the 
chapter  on  Anatomy. 

Combined  Methods:  Ahdoviino-anal,  Ahdomino-perineaJ,  Ahdomino- 
sacral. — A  combination  of  the  abdominal  with  the  other  methods  for  ex- 
tirpation of  the  rectum  has  been  suggested  from  time  to  time  during 
the  past  two  decades.  In  carcinomas  of  the  extreme  upper  end  of  the 
rectum  and  lower  portion  of  the  sigmoid  it  has  been  found  easier  to 
loosen  the  gut  from  its  higher  attachments  through  an  abdominal  in- 
cision than  through  the  perineal,  vaginal,  or  sacral  routes.  These  com- 
binations are  termed  the  ab domino-anal,  the  ahdomino-perineal,  and  the 
abdomino-sacral  methods. 

Abdoniino-anal  Method. — Maunsell  (London  Lancet,  August  37,  1892, 
p.  473)  first  suggested  this  operation.  He  opened  the  abdomen  by  me- 
dian incision  above  the  pubis,  incised  the  peritoneal  attachments  of  the 
bowel,  and  loosened  it  well  above  and  below  the  growth.  He  then  passed 
a  loop  of  tape  by  a  long  mattress  needle  from  the  abdomen  through  the 
rectum  and  out  of  the  dilated  anus.  With  this  loop  he  pulled  the 
neoplasm  down  through  the  anus,  thus  everting  the  lower  part  of  the 
rectum.  He  suggested  that,  if  the  tumor  were  large,  it  might  be  neces- 
sary to  incise  the  anus  back  to  the  coccyx  in  order  to  bring  the  growth 
outside  of  the  body.  The  tumor  thus  exposed  was  then  resected,  and 
the  healthy  ends  of  the  intestine  united  by  sutures.     The  everted  and 


EXTIRPATION  OF  THE  RECTUM 


843 


prolapsed  rectum  was  then  restored  to  its  position^,  the  peritoneal  wound 
sutured  from  the  abdominal  side,  and  the  abdominal  wound  closed  in 
the  ordinary  way. 

Weir  (Jour.  Amer.  Med.  Assn,  1901,  vol.  ii,  p.  801)  states  that  in 
a  trial  of  this  method  he  was  unable  to  bring  the  tumor  through  the 
divided  anus,  and  that  forcible  traction  upon  the  tape  enlarged  the 
opening  through  which  it  passed  into  the  bowel,  so  that  the  contents 
of  the  latter  es- 
caped into  the 
peritonaeum.  He 
therefore  modified 
the  operation  as 
follows: 

After  making 
an  abdominal  in- 
cision with  the  pa- 
tient in  the  Tren- 
delenburg posture 
and  forcing  the 
small  intestine  up 
into  the  abdom- 
inal cavity  with 
an  artificial  dia- 
phragm, he  ties 
the  inferior  mes- 
enteric artery  as 
it  passes  over  the 
promontory  of  the 
sacrum.  He  then 
loosens  the  sig- 
moid and  rectum 
by  incision  of  the 
peritonaeum  and 
blunt  dissection 
down  to  the  tip 
of  the  coccyx  and 

lower  border  of  the  prostate.  At  this  point,  below  the  tumor,  two 
iodoform  tapes  are  tied  around  the  gut  about  an  inch  aj^art,  and  the 
latter  is  cut  through  between  them  (Fig.  296).  The  upper-  portion  of 
the  bowel  is  then  dragged  out  through  the  superior  angle  of  the  abdom- 
inal wound  and  the  neoplasm  is  excised.  The  lower  end  of  the  rectum 
is  then  seized  by  forceps  in  the  hands  of  an  assistant,  who  everts  it 
through  the  anus.    A  long  forceps  is  then  carried  through  this  everted 


Fig.  296. — Abdomino-anal  Extirpation  of  High  Eectal  Cancer 
— Enucleation    of    Diseased  Portion   through    Abdominal 

KOUTE. 


844 


THE  ANUS,  RECTUM,  AND   PELVIC  COLON 


rectum  into  the  pelvis,  and  with  it  the  upper  bowel  is  grasped  and 
dragged  down  through  the  everted  lower  end.  Two  needles  are  then 
passed  through  the  invaginatcd  ends  in  order  to  maintain  the  parts  in 

position,  and  the  upper  and  lower 
ends  of  the  gut  are  sutured  together 
(Fig.  297).  The  fixation  needles  are 
then  removed  and  the  invaginated 
gut  is  restored  to  its  position  (Fig. 
298).  The  peritonaeum  is  then  sewed 
together  and  to  the  bowel  so  that  the 
general  abdominal  cavity  and  the 
pelvis  are  separated  from  each  other, 
and  the  abdominal  wound  is  closed. 
The  operation  is  completed  by  an  in- 
cision posterior  to  the  anus  and  Just 
in  front  of  the  coccyx,  extending  into 
the  pelvic  space  from  which  the  tu- 
mor has  been  removed,  and  through 
this  a  tube  is  introduced  to  secure 
drainage;  a  second  smaller  tube, 
wrapped  with  iodoform  gauze,  is 
carried  into  the  rectum  and  through 
the  sutured  area  to  facilitate  the 
escape  of  gas  and  prevent  the  intes- 
tinal contents  from  coming  in  con- 
tact with  the  wound. 

At  the  time  of  Weir's  report  the 

operation  had  been  employed  three 

times,  with  two  recoveries  and  one 

There  was  some  tendency  to  stricture  at  the  point  of  suture. 


Fig.  297. — Abdomixo-axal  Extirpatiox. 

Sigmoid  is  brougbt  dowo  through  everted 
rectum  and  sutured  after  method  of  Weir. 


death. 


but  this  ^^■as  overcome  by  the  passage  of  Wales  bougies.  The  strictest 
rules  of  asepsis  are  insisted  upon,  the  ends  of  the  bowel  art  each  point 
of  section  being  cauterized  by  carbolic  acid,  and  the  pelvis  is  repeatedly 
washed  with  sterilized  salt  solution  after  the  rectum  has  been  everted. 

Weir  advises  that  the  eversion  of  the  lower  bowel,  the  suturing  of 
the  ends  together,  their  replacement,  and  the  introduction  of  drainage- 
tubes  should  be  trusted  to  a  competent  assistant,  and  that  the  surgeon 
should  restrict  himself  to  the  interior  abdominal  work  in  order  that 
the  strictest  asepsis  may  be  maintained.  This  modification  of  ]\Iaunsell's 
method  is  a  fine  conception,  and  appears  to  be  well  w^orthy  of  further 
trial.  The  chief  difficulty  in  its  performance  will  be  found  in  loosening 
the  gut  sufficiently  to  invaginate  it  through  the  anus  without  impairing 
its  circulation.    'V\Tiere  the  superior  hsemorrhoidal  artery  is  tied  off,  the 


EXTIRPATION  OF  THE  RECTUM 


845 


chief  supply  to  tlie  lower  segment  of  tlie  gait  is  obliterated  with  the 
exception  of  that  slight  portion  furnished  b}^  the  middle  hasmorrhoidal 
artery.  It  sometimes  happens,  therefore,  that  the  anastomotic  circula- 
tion is  too  feeble  to  maintain  the  vitality  of  the  intestine,  and  gangrene 
occurs.  It  is  important,  therefore,  when  the  end  of  the  gut  is  cut  across, 
to  observe  whether  the  circulation  in  it  is  sufficient  to  supply  its  needs. 
AVhere  there  are  no  pumping  arteries  upon  transverse  section  it  is  better 
to  cut  the  gut  off  at  a  higher  level  until  such  are  found.  This  sug- 
gestion applies  -with  equal  force  to  the  sacral,  perineal,  and  abdominal 
methods.  The  author  has  seen  gangrene  occur  three  times  from  this 
default,  and  in  future,  whenever  he  fails  to  observe  a  satisfactory  blood 
supply  in  the  superior  segment  of  the  gut,  he  will  undoubtedly  carry 
the  latter  out  through  the  abdominal  opening  and  convert  it  into  an 
artificial  anus  rather  than  take  the  chances  of  this  accident. 

Abdomino-perineal  and  Ahdomino-sacral  Methods. — In  1884,  Czerny, 
in  attempting  to  remove  a  high  cancer  of  the  rectum  by  the  perineal 
method,  found  himself  unable  to 
complete  the  extirpation  from  be- 
low. Eather  than  leave  the  patient 
in  a  hopeless  condition,  he  boldly 
resorted  to  abdominal  incision  and 
completed  the  operation  through 
this  route.  This  was  the  first  appli- 
cation of  the  combined  method,  bat 
it  was  not  a  preconceived  procedure. 
Maunsell,  as  we  have  stated  else- 
where, was  the  first  to  conceive  the 
idea  of  premeditatedly  opening  the 
abdominal  cavity  for  the  extirpa- 
tion of  a  cancerous  rectum.  Cha- 
put  (Finet,  op.  cit.,  p.  338),  on 
August  27,  1894,  deliberately  per- 
formed a  median  laparotomy  to 
loosen  the  cancerous  rectum  from 
its  higher  attachments  before  ex- 
tirpating it  by  the  sacral  method. 
To  him,  perhaps,  should  be  ac- 
corded priority  in  the  combined 
sacro-abdominal  procedure.  Gau- 
dier, to  whom  this  priority  is  sometimes  attributed,  premeditatedly 
performed  the  abdomino-perineal  operation  in  Xovember,  1895,  more 
than  a  year  after  Chaput's  operation.  He  made  a  median  laparotomy, 
cut  the  gut  transversely  above  the  tumor,  loosened  its  lower  end  as 


Fig.  298.- 


Final   Steps  in  Abdomixo-anal 
extiepation. 


Peritoneal  cavity  closed,  intestinal  tract  re- 
stored, and  drainage-tube  fixed  in  retro- 
rectal space. 


846  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

iar  down  as  llic  iiiesorcc-Unii.  tlu'ii  li.xcd  I  he  upper  end  in  the  abdom- 
inal \vo\ind  for  an  artiiieial  anus,  and  iinally  dissected  the  rectum 
out  by  the  jierineal  route  from  below.  Cliallot  performed  this  same 
operation  with  some  modifications  only  a  month  later.  The  chief 
point  in  his  technique,  however,  consists  in  preliminary  ligature  of 
the  superior  ha?morrhoidal  artery  Just  before  it  passes  into  the  pelvic 
cavity.  He  therefore  appears  to  have  preceded  Weir  in  this  pre- 
caution. 

Boeckel  (Societe  de  chir.,  October  28,  1896),  in  removing  a  high 
cancer  by  the  Kraske  method,  found  himself  in  the  same  position  as 
Czernj',  and  was  forced  to  do  a  laparotomy  in  order  to  complete  the 
extirpation.  The  steps  which  he  advises  after  describing  his  case  are 
as  follows: 

Isolate  the  rectum  as  far  as  possible  through  the  sacral  route,  create 
an  artificial  anus  in  the  descending  colon  or  the  sigmoid  flexure  by 
cutting  the  gut  squarely  across  and  dragging  its  superior  end  out  of 
the  abdominal  wound,  then  loosen  all  tlie  intestine  below  this  point 
and  extirpate  it  by  the  sacral  way. 

The  writer  can  see  no  advantage  in  this  latter  suggestion.  If  the 
gut  has  been  liberated  entirely  from  below  before  the  laparotomy  is 
made,  what  possible  good  can  come  from  turning  the  patient  upon  his 
side  again  simply  to  draw  the  gut  out  from  below  instead  of  removing 
it  at  once  through  the  abdominal  wound?  In  such  cases  the  abdominal 
wound  should  be  made  wide  enough  to  thoroughly  manij)ulate  the  parts, 
and  this  turning  of  the  patient  backward  and  forward  not  only  disturbs 
the  relationship  of  the  abdominal  organs,  but  it  also  predisposes  to 
accidents  of  infection. 

All  the  combined  operations  described  above  leave  the  patient  with 
an  artificial  anus.  Giordano  (Clin.  Chir.,  Milano,  1896,  p.  463)  devised 
and  carried  out  a  combined  abdomino-perineal  operation  for  extirpation 
of  cancer  high  up,  which  he  completed  by  dragging  the  superior  seg- 
ment of  the  resected  gut  down  through  a  slit  in  the  gluteal  muscles  and 
suturing  it  to  the  skin.  Before  attempting  to  remove  the  rectum,  Gior- 
dano tied  both  internal  iliac  arteries.  It  is  not  stated  whether  this  was 
done  with  a  simple  view  of  controlling  ha?morrhage  or  with  the  intent 
of  starving  out  the  cancerous  process  by  cutting  off  its  blood  supply, 
as  has  been  suggested  by  Pryor  and  others  in  cancer  of  the  uterus. 
Shortly  after  this  Quenu  (Societe  de  chir.,  November  -1,  1896)  performed 
a  similar  operation,  but  advised  approaching  the  organ  through  the 
sacral  or  perineal  way  first,  and  then  completing  the  abdominal  part  of 
the  operation  afterward.  Reverdin  reversed  this  procedure  (Quenu  and 
Hartmann,  op.  cit.,  ii,  p.  292)  in  a  remarkable  manner.  After  opening 
the  abdomen  and  incising  the  gut  transversely  above  the  neoplasm,  he 


EXTIRPATION   OF  THE   RECTUM  847 

loosened  the  upper  segment  for  12  or  15  centimeters,  dragged  it  out 
through  the  upper  angle  of  the  abdominal  wound,  and  tied  into  it  a 
glass  e3dinder  with  a  depressed  groove  around  one  end,  into  which  a 
ligature  drawn  around  the  gut  fitted,  thus  holding  the  tube  in  position. 
The  gut  was  thus  sutured  with  12  centimeters  entirely  outside  of  the 
bowel.  To  the  end  of  the  glass  tube  which  was  thus  fitted  in  the  intes- 
tinal caliber  a  rubber  drainage-tube  was  attached,  which  was  carried 
into  a  basin  beneath  the  bed.  All  these  precautions  were  taken  to  pre- 
vent the  possible  soiling  of  the  wound  by  the  discharges  from  the  intes- 
tinal canal.  The  lower  segment  of  the  gut  containing  the  neoplasm  was 
then  excised,  the  peritoneal  toilet  completed,  and  the  wound  dressed 
in  the  usual  way.  He  states  that  his  patient  died  three  days  later  from 
exhaustion  from  feebleness  ("  par  I'epuisement,  par  faiblesse '').  To 
those  familiar  with  this  class  of  surgery,  Eeverdin's  description  will 
carry  the  conviction  that  the  cause  of  death  in  this  instance  was  nothing 
more  nor  less  than  septic  peritonitis  of  a  subacute  type,  notwithstanding 
all  the  precautions  which  he  took  to  avoid  fa?cal  extravasation. 

On  July  30,  1896,  the  author  removed  by  abdominal  section  a  large 
carcinoma  of  the  sigmoid  and  upper  rectum  as  follows:  The  abdomen 
was  opened  in  an  oblique  line,  beginning  just  above  the  pubis  and 
extending  upward  to  a  point  1  inch  inside  of  the  left  anterior  superior 
spine  of  the  ilium.  The  sigmoid  flexure  was  dragged  upward  and  out 
of  the  wound,  its  mesentery  incised  about  midway  between  the  gut  and 
sacrum,  beginning  at  a  point  2  inches  above  the  tumor;  the  vessels 
were  caught  with  pressure  forceps  as  the  dissection  proceeded.  The 
superior  hgemorrhoidal  artery  was  cut  during  this  process  and  tied  off. 
After  the  section  of  gut  containing  the  tumor  was  loosened  down  to  a 
point  about  opposite  the  third  sacral  vertebra,  the  gut  was  surrounded 
with  two  ligatures  below  the  growth,  and,  being  thoroughly  protected  by 
gauze  pads,  was  cut  through  transversely.  The  upper  segment,  contain- 
ing the  neoplasm,  was  drawn  outside  the  wound,  a  ligature  was  placed 
around  it  above  the  growth,  and  it  was  again  cut  off  below  this  ligature, 
thus  extirpating  the  neoplasm.  The  cut  ends  of  the  two  segments  were 
cauterized  with  piire  carbolic  acid  and  covered  with  iodoform  gauze. 
The  patient  was  then  turned  upon  his  side,  a  lateral  sacral  incision  was 
made,  and  the  upper  end  of  the  lower  segment  was  dissected  out  and 
dragged  through  this  wound;  with  a  long  forceps  the  upper  segment 
was  then  seized,  brought  out  through  the  sacral  wound,  and  an  end-to- 
end  union  of  the  two  parts  was  accomplished  by  Czerny-Lembert  su- 
tures. The  gut  was  then  replaced  in  the  pelvis,  gauze  drainage  was 
placed  around  the  point  of  union,  and  the  sacral  wound  left  open. 
The  patient  was  then  turned  upon  his  back  again,  the  peritoneal  floor 
of  the  pelvis  was  sutured,  and  the  abdominal  wound  closed  without  any 


848  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

drainage.  The  patient  died  iqjon  the  I'oiuih  day,  supposedly  i'l-oni  sup- 
pression of  urine,  but  later  observations  lead  us  to  conelude  that  the 
true  cause  was  sepsis. 

Following  in  the  footsteps  of  Giordano,  Quenu  has  formulated  a 
technique  for  the  combined  operation,  as  follows: 

First,  open  the  abdomen  in  a  median  line  and  ligate  both  hypo- 
gastric arteries. 

Second,  free  the  sigmoid  loop,  cut  it  across  between  two  ligatures 
with  a  thermo-cautery,  and  establish  an  artificial  anus  in  the  left  in- 
guinal region  by  means  of  the  upper  segment. 

Third,  liberate  the  lower  segment  by  incision  of  the  lateral  and 
posterior  peritoneal  bands  and  dull  dissection  below  this  point  down 
to  the  tip  of  the  coccyx  and  lower  border  of  the  prostate.  In  this 
dissection  the  superior  ha^morrhoidal  artery  will  have  to  be  tied.  The 
intestine  thus  loosened  is  dropped  down  into  the  pelvis,  covered  over 
with  sterilized  gauze,  and  the  abdominal  wound  is  rapidly  closed. 

The  patient  is  then  placed  in  the  lithotomy  position,  the  perianal 
region  recleansed,  and  the  lower  portion  of  the  rectum  is  extirpated  by 
the  perineal  method  heretofore  described.  In  establishing  the  artificial 
anus  Quenu  drags  the  gut  out  through  an  incision  in  the  abdominal 
wall  in  the  inguinal  region  and  sutures  it  to  tlie  difi^erent  layers.  He 
leaves  the  ligature  around  the  protnuling  end  for  several  hours  in 
order  that  adhesion  between  the  peritoneal  surfaces  and  the  wound  may 
take  place  before  any  danger  of  infection  from  the  escape  of  freces  can 
occur.    Finally,  the  abdominal  wound  is  sealed  off  by  "  adhesol." 

The  author  has  modified  this  technique  in  his  operations  by  the 
combined  method,  as  follows:  The  abdomen  is  opened  by  a  long  colos- 
tomy incision  on  the  left  side.  The  sigmoid  is  dragged  out  of  the  abdo- 
men and  cut  transversely  between  two  ligatures  at  a  point  1  inch  above 
the  growth,  the  ends  being  cauterized  with  carbolic  acid  and  covered 
with  rubber  protective.  The  lower  segment  is  then  dissected  out  without 
tying  the  hypogastric  arteries.  The  superior  ha?morrhoidal  is  either 
ligatured  beforehand  (Fig.  299)  or  caught  and  tied  if  cut.  After  dis- 
section has  gone  below  the  tumor,  the  latter  is  excised  between  two  liga- 
tures and  removed  from  the  abdominal  cavity.  If  end-to-end  union 
between  the  remaining  segments  is  feasible  it  is  employed;  if  it  is  not, 
the  lower  segment  is  invaginated  and  closed  by  sutures.  The  peritoneal 
breach  below  is  then  sutured,  and  an  artificial  anus  is  made  after  the 
manner  of  Bailey,  and  the  abdomen  closed. 

Whei-e  the  anus  needs  to  be  extirpated  no  abdominal  operation  is 
necessary;  the  perineal  or  sacral  methods  will  accomplish  all  that  is 
justifiable  in  these  cases,  and  laparotomy  only  adds  to  the  shock  and 
exposes  the  ])atient  to  greater  danger  of  sepsis.     The  mortality  from 


EXTIRPATION  OF  THE  RECTUM 


849 


these  combined  methods  has  been  very  high,  and  they  should  not  be 
employed  save  in  exceptional  cases. 

Disposition  of  the  Intestinal  Ends. — Operations  by  the  sacral  and 
abdominal  methods  largely  resolve  themselves  into  resections  of  the 
intestine.  Under  such  circumstances  one  has  always  to  deal  with  two 
intestinal  ends,  and  the  disposition  of  these  is  a  question  of  much  im- 
portance. Kraske  (Centralblatt  f.  Chirur.,  1891,  S.  912)  in  his  earlier 
operations  only  sutured  the  anterior  circumference  of  the  rectum  in 


Fig.  299. — Exposure  or  ILemorrhoidal  axd  Sigmoidal  Arteby  in  Abdominal 
Extirpation  of  the  Eectum. 


order  to  prevent  retraction  of  the  two  ends,  and  left  the  posterior  por- 
tion open  so  that  the  fsecal  materials  could  be  thus  discharged  without 
any  obstruction.  Later,  however,  he  advised  suturing  the  entire  cir- 
cumference, although  admitting  that  leakage  and  fistula  would  likely 
occur. 

Hochenegg  dissected  off  the  mucous  membrane  from  the  lower  end 
of  the  rectum  and  invaginated  the  upper  segment  of  the  gut  through 
this  freshened  canal,  suturing  it  to  the  skin  about  the  margin  of  the 
anus.  This  is  a  most  excellent  method  where  the  upper  segment  is  suffi- 
ciently long  to  be  brought  down  through  the  anus  without  undue  ten- 
54 


850  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

siou  or  interference  with  its  circulation.  In  cases  where  the  length  is 
not  sufficient,  the  gut  may  be  sutured  in  the  upper  angle  of  the  sacral 
wound,  thus  establishing  an  artificial  sacral  anus,  for  the  control  of 
which  Hochenegg  has  devised  an  ingenious  and  quite  satisfactory  truss. 
Perron  (Gaz.  hebdoni.  de  Bordeaux,  1890)  described  a  method  similar  to 
that  of  Maunsell.  He  everted  the  lower  end  of  the  rectum,  dragged  the 
upper  segment  down  through  this,  and  sutured  the  two  ends  of  the 
gut  together  by  circular  suture.  He  then  allowed  the  parts  to  slip  back 
into  position,  and  introduced  a  drainage-tube  through  the  anus  up 
beyond  the  sutured  area.  The  author  has  performed  this  method  twice 
with  very  satisfactory  results. 

In  cases  in  which  a  preliminary  artificial  anus  has  been  made,  the 
treatment  of  the  intestinal  ends  will  depend  largely  upon  whether  it 
has  been  determined  to  maintain  this  anus  permanently  or  only  as  a 
temporary  measure.  When  it  is  seen  upon  abdominal  exploration  that 
there  is  no  probability  of  reestablishing  the  normal  fa-cal  channel,  then 
a  ])ermanent  artificial  anus  should  be  made,  either  by  the  Bailey  method 
or  by  cutting  the  gut  transversely  across,  closing  the  lower  end  and 
dropping  it  back  into  the  abdomen,  and  establishing  the  new  anus  in 
the  upper  segment,  after  the  manner  of  Witzel.  The  extirpation  is 
undertaken  some  days  later,  and  the  treatment  of  the  section  below  the 
artificial  anus  will  depend  largely  upon  the  type  of  inguinal  anus  em- 
ployed. If  the  gut  has  been  cut  across  and  the  segment  dropped  back 
into  the  abdominal  cavity,  it  may  be  removed  in  its  entirety  along  with 
the  tumor,  it  may  be  closed  after  the  tumor  has  been  resected  and  the 
closed  segment  left  to  atrophy,  or  its  lower  end  may  be  sutured  in  the 
upper  angle  of  the  sacral  wound.  If  the  artificial  anus  has  been  made 
after  the  ordinary  spur  method,  with  a  double-barreled  aperture,  the 
lower  leg  of  this  spur,  after  the  tumor  has  been  resected  from  below, 
may  be  everted  through  the  inferior  aperture  of  the  artificial  anus  and 
clamped  or  tied  off  with  a  ligature  (Quenu).  It  may  also  be  fixed  in 
the  upper  angle  of  the  sacral  wound,  where  it  will  form  a  sort  of  mucous 
fistula,  which  eventually  atrophies  and  closes  spontaneously.  Some  sur- 
geons simply  tie  a  ligature  around  it  and  leave  the  gut  loose  in  the 
wound.  This  is  a  dangerous  experiment,  for  sepsis  is  likely  to  follow, 
however  thorough  the  drainage.  The  invagination  and  excision  of  the 
segment  through  the  lower  opening  of  the  artificial  anus  is  more  satis- 
factory when  it  can  be  accomplished,  but  sometimes  the  attachment 
of  the  mesosigmoid,  adhesions,  or  other  complications  render  this  al- 
most impossible,  and  one  must  resort  to  the  other  methods. 

Where  the  two  ends  of  the  bowel  can  be  brought  together  after  re- 
section of  the  tumor  they  may  be  united  either  by  suturing  or  by  the 
aid  of  a  Murphy  button.     The  author  has  employed  the  latter  methqd 


EXTIRPATION  OP  THE  RECTUM  851 

a  number  of  times,  and,  while  it  does  not  prevent  the  formation  of  a 
fistula,  it  facilitates  the  bringing  of  the  ends  together  and  enables  one 
to  introduce  a  supplementary  row  of  Lembert  sutures  around  it  much 
more  rapidly.  Mayo,  ]\Ieyer  (Annals  of  Surgery,  1896,  p.  687),  and 
Marcy  (Boston  Med.  and  Surg.  Jour.,  1893,  p.  561)  have  all  employed 
the  Murphy  button  in  these  cases,  but  in  almost  every  instance  posterior 
fistula  has  followed  its  use. 

Where  the  upper  segment  is  sufficiently  long  to  accomplish  it,  the 
author  prefers  the  Perron  or  Hochenegg  methods  of  treating  the  intes- 
tinal ends;  but  in  cancers  high  up  in  the  rectum  these  are  not  feasible, 
and  one  will  find  the  Murphy  button  of  great  assistance  in  such  cases. 

Whatever  method  is  employed  in  the  treatment  of  the  intestinal 
ends,  it  is  necessary  to  thoroughly  dilate  the  s|)hincter  or  incise  it  pos- 
teriorly in  order  to  obviate  any  obstruction  to  the  passage  of  fsecal 
material  and  gases  from  the  bowel.  When  end-to-end  suturing  has  been 
employed,  one  should  also  pass  a  firm  rubber  drainage-tube  through  the 
anus  and  above  the  line  of  anastomosis  in  order  to  prevent  any  tension 
upon  these  parts  from  the  accumulations  of  gases  or  fsecal  material. 

Complications  in  Extihpation. — The  accidents  and  complications 
connected  with  extirpation  of  the  rectum  for  malignant  disease  may  be 
described  as  immediate  and  remote. 

Immediate  Complications. — Haemorrhage  is  ordinarily  spoken  of  as 
one  of  the  chief  complications  and  contraindications  in  extirpation  of 
the  rectum.  It  can  not  be  denied  that  operation  by  the  perineal  method 
is  attended  by  considerable  bleeding,  and  on  this  account  it  is  inadvisable 
in  cases  already  weakened  by  haemorrhages  from  the  growth  itself.  Tlie 
operation  by  the  sacral  route,  if  conducted  according  to  the  technique 
already  laid  down,  is  not  accompanied  by  any  excessive  loss  of  blood. 
The  application  of  the  ligature  or  clamp  to  the  intestine  before  at- 
tempting to  dissect  out  the  lower  portion  of  the  rectum  absolutely 
precludes  the  loss  of  much  blood  during  this  part  of  the  operation. 
The  author  has  succeeded  in  extirpating  the  rectum  more  than  ten 
times  without  tying  over  four  vessels.  The  secret  of  this  lies  in  the 
fact  that  the  same  artery  is  cut  many  times  in  the  course  of  extirpa- 
tion, and  if  the  operator  stops  to  catch  and  tie  it  each  time,  the  opera- 
tion will  be  unduly  prolonged  and  an  unnecessary  amount  of  blood  lost. 
If  the  superior  dissection  and  dragging  down  of  the  gut  is  all  accom- 
plished first  and  the  peritonaeum  closed  before  the  gait  is  cut  across, 
the  lower  segment  may  be  rapidly  excised,  gauze  compresses  being 
crowded  into  the  wound  as  the  dissection  proceeds,  and  a  very  small 
amount  of  blood  will  be  lost.  As  soon  as  the  excision  is  completed 
these  gauze  compresses  can  be  removed  and  the  two  or  three  vessels 
which  bleed  can  be  caught  and  tied.     Practically  the  middle  sacral, 


852  THE  ANUS,   KECTUM,   AND  PELVIC  COLON 

the  right  lateral  sacral,  and  two  middk'  lui'iuorrhoidal  arteries  are  all 
that  are  necessary  to  ligate.  In  only  one  case  operated  by  this  method 
has  there  been  any  excessive  haemorrhage,  and  this  was  due  to  the  fact 
that  undue  traction  upon  the  gut  tore  the  superior  haemorrhoidal  artery 
off  at  the  promontory  of  the  sacrum,  and  the  presence  of  the  gut  in 
the  wound  rendered  the  catching  and  tying  of  this  exceedingly  difficult. 
This  accident  can  be  entirely  avoided,  as  the  gut  should  be  brought 
down  by  clean  dissection  wdthout  dragging  and  tearing. 

Escape  of  Intestinal  Contents  into  Wound. — Another  accident,  and 
one  of  the  most  serious  complications  in  extirpation,  is  the  rupture  of 
the  intestinal  wall  and  escape  of  its  contents  into  the  wound.  This  is 
also  occasioned  in  the  majority  of  instances  by  undue  traction  in  at- 
tempting to  loosen  the  gut  by  dull  dissection.  It  may  also  occur  from 
attempts  to  separate  adhesions  of  the  peritoneal  cul-de-sac,  or  between 
the  rectum  and  other  organs,  by  blunt  dissection.  The  best  method 
of  avoiding  this  consists  in  isolating  the  gut  around  its  right  side  by 
clean  dissection  with  scissors  until  the  peritonaeum  is  opened.  As  soon 
as  this  is  accomplished  the  lateral  peritoneal  folds  should  be  cut  off 
close  to  the  rectal  wall.  This  will  allow  the  gut  to  be  brought  down  a 
considerable  distance  so  that  its  healthy  portion  can  be  grasped.  Upon 
this  a  clamp  should  be  placed,  and  then  the  mesorectum  can  be  cut 
loose  close  to  the  sacrum,  thus  enabling  one  to  rotate  the  neoplasm 
and  complete  the  dissection  upon  the  left  side  without  any  undue  drag- 
ging upon  the  diseased  portion.  The  adhesions  should  be  handled  very 
gently,  and  those  between  the  rectum  and  uterus  or  prostate  should  be 
shaved  off  rather  than  torn  loose.  Wherever  it  is  possible,  the  entire 
intraperitoneal  dissection  should  be  completed  and  the  gut  drawn  dow^n 
to  the  extent  desired  before  it  is  cut  across;  the  section  should  always 
be  accomplished  well  outside  of  the  wound,  and  with  the  latter  com- 
pletely protected  by  gauze  packing. 

Injury  to  other  Organs. — Injury  to  the  ureters  and  bladder  have 
frequently  occurred  during  the  course  of  rectal  extirpation  by  the  sacral 
method.  A  thorough  knowledge  of  the  anatomical  relations  alone  will 
enable  one  to  avoid  these  accidents.  They  are  often  occasioned  by  drag- 
ging upon  the  gut  before  it  has  been  loosened  from  its  lateral  and  an- 
terior peritoneal  attachments.  These  accidents  also  emphasize  the  im- 
portance of  opening  the  peritoneal  cavity  early  in  the  operation  in  order 
to  establish  one's  landmarks.  Twice  in  cases  where  the  cul-de-sac  has 
been  obliterated  by  inflammatory  adhesion  the  author  has  accidentally 
cut  into  the  bladder,  but  the  wounds  were  immediately  sutured,  and 
apparently  the  accidents  did  not  interfere  with  the  subsequent  course 
of  the  operation.  In  one  case  the  ureter  was  torn  across,  and  an  attempt 
was  made  to  restore  its  caliber.     This  patient  died  forty-eight  hours 


EXTIRPATION   OF   THE  RECTUM  853 

later,  and  therefore  the  results  of  this  effort  could  not  be  determined. 
The  author  knows  of  one  case  in  which  both  ureters  were  torn  off  by 
attempting  too  much  blunt  dissection  in  this  operation;  great  care  is 
necessary  to  avoid  these  accidents,  and  it  is  much  safer  to  separate  the 
parts  by  clean  incision  than  by  dragging  and  tearing. 

Post-operative  Complications. — The  chief  complication  which  follows 
these  operations  is  sepsis.  As  has  been  stated,  over  75  per  cent  of  the 
deaths  occurring  from  extirpation  of  cancer  of  the  rectum  are  caused 
by  infection.  Wliether  this  is  due  to  faulty  technique,  to  the  escape 
of  fffical  material  during  the  operation,  to  rupture  of  the  sutures  after 
the  operation,  or  to  the  presence  of  bacilli  in  the  j^erirectal  tissues  at 
the  time  of  operation,  it  is  impossible  to  say.  To  the  present  time  no 
technique  has  been  devised  which  will  positively  secure  asepsis  in  opera- 
tions of  this  type.  The  precautions  which  were  suggested  for  the  pre- 
vention of  the  escape  of  faecal  matter  into  the  wound,  the  closure  of 
the  peritoneal  cavity  before  the  gut  was  incised,  the  avoidance  of  intro- 
ducing the  linger  into  the  rectum  and  then  into  the  wound,  are  all  im- 
f)ortant  in  the  prevention  of  this  complication.  While  it  seems  im- 
jjossible  to  avoid  a  certain  amount  of  suppuration  after  extirpation,  if 
the  peritoneum  can  be  protected  this  complication  will  not  often  prove 
serious.  Some  cases  have  succumbed  to  prolonged  suppuration,  but  these 
compose  a  very  small  percentage  of  the  fatalities. 

Gangrene  is  the  next  most  serious  post-operative  complication.  This 
may  be  due  to  three  causes:  First,  deficient  blood  supply  of  the  superior 
segment,  which  has  been  referred  to.  Second,  too  great  tension  upon 
the  superior  segment.  ^Miile  the  blood  supply  may  be  adequate,  if 
the  gut  is  sutured  in  a  taut  condition  this  may  result  in  the  acute 
flexure  and  occlusion  of  its  arterial  supply,  which  will  result  in  gangrene 
of  its  lower  end,  with  retraction  or  systemic  infection,  which  brings 
about  a  fatal  end.  Third,  it  may  occur  from  infection.  In  the  first 
two  instances  the  condition  develops  within  the  first  twenty-four  hours; 
in  the  last,  the  gut  may  appear  perfectly  healthy  for  two  or  three  days, 
and  then  entirely  slough  away.  There  is  no  way  to  avoid  this  except 
through  the  most  rigid  asepsis.  This  complication  more  than  any  other 
inclines  the  author  to  the  systematic  employment  of  a  preliminary  colos- 
tomy, as  he  has  seen  gangrene  occur  in  but  one  case  where  this  has 
been  done. 

Abnormal  Anus. — In  certain  cases  after  the  tumor  has  been  resected 
it  will  be  found  impossible  to  bring  the  gut  down  to  the  anus  or  the 
lower  end  of  the  resected  rectum.  Under  such  circumstances  it  be- 
comes necessary  to  establish  the  anus  in  some  abnormal  position.  This 
may  be  done  in  the  inguinal  region,  after  the  method  of  Bailey,  or,  if 
the  superior  segment  is  long  enough,  it  may  be  brought  down  and 


854  THE  ANUS,   RECTUM,   AND   PELVIC   COLON 

stitched  to  the  skin  at  the  lower  end  of  the  coccyx;  or,  finally,  the  gut 
may  be  sutured  in  the  upper  angle  of  the  sacral  wound.  The  latter 
position  is  that  advised  by  Hochenegg.  The  author  is  in  favor  of  this 
procedure  when  the  sphincters  have  been  preserved;  for,  thanks  to  the 
prolapse  which  often  occurs,  it  is  occasionally  possible  at  a  later  period 
to  dissect  the  gut  loose  from  this  position  and  reestablish  the  anus  in 
its  normal  position.  When  the  sphincters  are  removed,  however,  better 
faecal  control  can  be  obtained  through  the  modern  inguinal  anus. 

Prolapse  of  the  Gut. — Following  extirpation  of  the  rectum,  especially 
where  the  anus  is  established  in  the  sacral  region,  prolapse  of  the  gut 
is  very  likely  to  occur.  Sometimes  when  the  anus  is  established  in 
its  normal  position,  an  excessive  mucous  prolapse  takes  place.  In 
the  first  instance,  where  the  prolapse  is  complete  and  of  sulticient 
length,  the  gut  may  be  dissected  out  from  its  attachments,  Ijrought 
down  and  sutured  at  the  normal  site  of  the  anus  after  the  patient  has 
regained  his  strength.  Where  the  prolapse  consists  of  mucous  mem- 
brane alone,  this  may  be  excised  after  the  manner  of  Whitehead,  or  it 
may  be  clamped  off  and  cauterized,  as  has  been  described  in  the  sec- 
tion on  incomplete  prolapse. 

Incontinence. — Incontinence  of  faeces  is  a  very  frequent  complication 
following  extirpation  of  the  rectum.  To  avoid  this,  Gersuny  (Cen- 
tralbl.  f.  Chirurg.,  1893,  S.  553)  has  proposed  twisting  the  gut  two  or 
three  times  around  before  it  is  sutured  in  position.  This  procedure 
has  been  adopted  by  numerous  surgeons,  notably  by  Gerster,  and  seems 
for  the  time  being  to  be  quite  effectual.  It  does  not  remain  permanent, 
however,  for  in  the  large  majority  of  cases  the  incontinence  returns 
after  a  longer  or  shorter  period.  In  order  to  overcome  this,  Willems 
(Centralbl.  f.  Chir.,  1893,  S.  401)  proposed  carrying  the  superior  segment 
through  the  fibers  of  the  gluteus  maximus  muscle,  thus  constituting  a 
sphincter  ani.  Witzel  (ihid.,  189-1,  pp.  937  and  1262)  first  carried  out 
this  procedure,  and  with  considerable  success.  Eydygier  {op.  cit.)  car- 
ried the  gut  through  the  gluteus  maximus  and  pyramidal  muscles,  and 
combined  with  this  the  torsion  of  Gersuny.  Where  the  sphincter  mus- 
cles are  involved  in  the  neoplasm  and  it  is  necessary  to  remove  them,  one 
should  always  establish  a  permanent  inguinal  anus  before  attempting 
to  extirpate  the  new  growth. 

Stricture. — Stricture  of  the  rectum  of  greater  or  less  degree  has 
occurred  in  many  of  the  cases  of  resection,  and  even  in  a  larger  percent- 
age of  the  cases  of  ampntation.  This  complication  is  unavoidable.  It  can 
be  limited,  however,  by  the  assiduous  passage  of  bougies,  which  should  be 
begun  about  ten  days  after  the  operation.  If  the  patient  is  taught  to  use 
the  bougie  himself,  the  caliber  of  the  gut  may  be  practically  maintained, 
and  the  stricture  will  not  constitute  a  serious  complication. 


EXTIRPATION  OP   THE   RECTUM  855 

Functional  Complications. — DiarrhcEa  and  constipation  are  among 
the  post-operative  complications  of  this  operation.  They  occur  abont 
equally  in  a  given  number  of  operations,  and  sometimes  alternate  with 
each  other  from  day  to  day.  The  cause  of  the  diarrhoea  may  be  reflex 
irritation  or  infection.  The  treatment  consists  in  thoroughly  cleaning 
out  the  intestinal  canal,  irrigating  the  colon  with  astringent  solutions, 
and  regulating  the  diet  in  such  a  manner  that  the  smallest  amount  of 
detritus  possible  will  be  produced.  The  constipation  should  be  treated 
according  to  the  principles  laid  down  in  the  chaj)ter  upon  that  subject. 

Injury  to  the  nerves  during  the  operation  of  extirpation  has  been 
frequently  mentioned  as  the  cause  of  incontinence.  The  author  has  not 
had  the  misfortune  to  observe  any  accidents  of  this  kind.  It  is  irrational 
to  suppose  that  such  operations  as  those  of  Bardenheuer  and  Eose 
could  do  otherwise  than  result  in  some  alteration  of  the  nerve  supply 
to  the  lower  end  of  the  intestinal  canal.  In  operations,  however,  re- 
stricted to  that  part  of  the  sacrum  below  the  third  sacral  foramina,  no 
grave  injury  of  this  character  is  likely  to  occur. 

Conclusions. — After  this  somewhat  prolonged  discussion  of  the  vari- 
ous methods  employed  in  extirpation  of  the  rectum,  it  is  incumbent 
to  express  an  opinion  as  to  when  such  operations  should  be  undertaken 
and  the  preference  in  the  selection  of  methods.  It  was  stated  that  all 
cancers  should  be  extirpated  which  are  confined  to  the  intestinal  wall, 
are  movable,  and  are  not  complicated  by  ganglionic  or  metastatic  ex- 
tension; adhesion  to  the  bladder,  uterus,  or  the  prostate  does  not  con- 
stitute a  positive  contraindication  to  the  removal  of  the  neoplasm; 
neither  does  enlargement  of  the  inguinal  glands,  as  this  may  be  en- 
tirely inflammatory.  The  same  may  be  said  with  regard  to  ganglionic 
enlargements  in  the  sacral  cavity. 

The  elevation  of  the  tumor  in  the  intestinal  tract  does  not  in  any 
way  limit  the  indications  for  extirpation.  Operations  upon  carcinoma 
of  the  rectum,  involving  the  uterine  or  genito-urinary  organs,  are  only 
justiflable  upon  the  demand  of  the  invalid.  The  patient  has  the  right 
to  take  a  desperate  chance  for  his  life,  but  it  is  not  right  for  the  sur- 
geon to  induce  him  to  undertake  this  chance  against  his  will,  for  the 
probability  in  such  cases  is  a  fatal  termination. 

The  Choice  of  Method. — JSTo  one  method  of  procedure  is  aiDplicable 
to  all  cases  of  carcinoma  of  the  rectum  and  sigmoid.  The  method 
to  be  pursued  in  any  individual  case  will  depend  wpon  the  location 
and  extent  of  the  tumor,  the  patient's  physical  condition,  and,  flnally, 
upon  the  average  results  from  the  difl'erent  operations.  It  is  customary 
in  discussing  the  choice  of  operations  to  divide  the  rectum  into  four 
or  five  sections,  indefinitely  described  as  anal,  subampullary,  ampullary, 
recto-sigmoidal,  and  sigmoidal.    Practically  there  are  but  three  divisions 


856  THE  ANUS,   RECTUM,   AND   PELVIC  COLON 

— the  infraperitoneal,  the  supraperitoneal,  and  tlie  sigiiioidal.  All  opei-- 
able  carcinomas  below  the  peritoneal  cul-de-sac  demand  a  practical  am- 
putatioii  of  the  lower  end  of  the  gut,  with  or  without  removal  of  the 
sphincters.  Where  the  growth  is  limited  to  this  lower  portion,  there 
is  no  longer  any  question  as  to  choice  of  operation.  The  perineal 
method  should  be  invariably  adopted  on  account  of  its  low  mortality 
and  the  comparative  absence  of  shock  which  follows  it.  Unquestionably 
there  is  more  haemorrhage  by  this  method,  and  it  is  more  frequently 
followed  by  an  ulcerative  area  at  the  lower  end  of  the  rectum;  but  inas- 
much as  free  drainage  is  afforded  through  the  anus,  fatalities  from 
sepsis  are  comparatively  rare.  The  modified  method  of  Quenu  is  a 
large  step  in  advance  of  any  other  technique  for  perineal  extirpation, 
and  if  it  is  carefully  conducted  the  immediate  mortality  ought  not 
to  be  above  10  per  cent.  This  operation,  as  Quenu  has  pointed  out, 
is  applicable  to  tumors  much  higher  up,  but  it  is  not  so  satisfactory 
as  the  sacro-coccygeal  route  in  tumors  located  above  the  peritoneal  re- 
flection— that  is,  more  than  3  inches  from  the  anus. 

In  tumors  confined  to  the  rectum  proper — that  is,  below  the  third 
sacral  vertebra  and  removed  more  than  1  inch  from  the  upper  border 
of  the  internal  sphincter — the  sacral  method  of  approach,  especially 
the  Eehn-Rydygier  bone-flap  operation,  is  preferable.  In  an  experience 
of  over  20  cases  by  this  method,  the  author  has  not  seen  one  in  wdiich 
survival  after  the  operation  was  not  follow^ed  by  comparatively  good 
restoration  of  the  bony  floor  of  the  pelvis.  He  is  decidedly  in  favor 
of  suturing  the  bone  back  in  position,  leaving  the  horizontal  portion 
of  the  wound  open  for  drainage.  In  many  cases  excision  of  the  coccyx 
gives  all  the  room  necessary  for  extirpation,  but  one  can  never  tell 
beforehand  whether  it  will  or  not;  therefore  it  is  better  to  adopt  the 
bone-flap  operation  in  the  first  place.  It  is  rapid,  efl'ectual,  and  by  it 
any  growth  of  the  rectum  or  lower  sigmoid  can  be  removed. 

For  tumors  situated  above  the  recto-sigmoidal  juncture,  the  abdom- 
inal method,  first  suggested  by  Kelly,  seems  to  give  excellent  results. 
Wherever  the  superior  limits  of  the  growth  can  not  be  reached  by  the 
finger  through  the  anus,  abdominal  exploration  should  always  be  em- 
ployed; and  under  these  circumstances  it  is  wdse  to  complete  the  opera- 
tion by  this  route  at  the  time,  if  feasible,  or  at  least  to  establish  an 
artificial  anus  preliminary  to  subsequent  extirpation  by  the  perineal  or 
sacral  route.  If  during  such  an  exploration  the  growth  is  determined 
to  be  of  a  recto-sigmoidal  nature,  and  the  patient's  condition  justifies 
the  same,  one  may  proceed  by  the  combined  method,  adopting  Weir's 
modification  of  IMaunsell's  operation  or  the  modified  technique  of  Quenu. 
If  the  patient  is  feeble,  and  there  is  an  accumulation  of  hard  facal  masses 
above  the  neoplasm  at  the  time  of  such  an  exploration,  one  should  not 


EXTIRPATION   OF   THE   RECTUM 


857 


attempt  to  extirpate  the  tumor  until  this  accumulation  has  been  relieved 
through  the  establishment  of  an  artificial  inguinal  anus.  The  preference 
of  the  French^  and  some  American  surgeons,  for  a  permanent  inguinal 
anus  in  all  carcinomas  of  the  rectum  is  not  shared  by  the  writer.  Just 
as  good  and  permanent  results  can  be  obtained  through  the  reestablish- 
ment  of  the  normal  exit  to  the  intestinal  canal  where  the  limits  of  the 
growth  admit  of  the  resected  ends  being  brought  in  apposition.  The 
mental  effect  of  the  artificial  anus  upon  these  patients  is  distinctly 
unfortunate.  It  is  true  that  by  the  modern  methods  one  can  establish 
a  comparatively  continent  inguinal  anus;  at  the  same  time  this  abnor- 
mality in  sensitive  patients  is  always  a  great  source  of  annoyance  and 
depression.  "Where,  however,  upon  abdominal  exploration  it  is  clear 
that  restoration  of  the  intestinal  canal  can  not  be  safely  made,  one  should 
not  hesitate  to  establish  a  permanent  inguinal  anus  at  once.  The  estab- 
lishment of  an  artificial  anus  as  a  preliminary  to  extirpation  of  the 
reetmn  is  undoubtedly  a  safeg-uard  to  the  procedure;  it  enables  one  to 
obtain  by  irrigation  through  the  lower  end  of  the  inguinal  anus  a  more 
healthy  and  less  septic  condition  of  the  intestinal  canal  below;  it  obviates 
the  danger  of  soiling  the  operative  field  during  the  operation,  and  also 
that  of  fffical  extravasation  should  the  sutures  give  way  subsequent  to  the 
union  of  the  ends  of  the  intestine.  At  the  same  time,  where  the  growth 
is  low  down  and  it  is  possible  to  bring  the  superior  segment  well  below 
the  peritoneal  reflection  or  out  through  the  anus,  one  may  avoid  the 
necessity  of  colotomy  and  subsequent  closure  with  comparative  safety. 
However,  in  patients  who  are  already  septic  and  feeble,  one  should  take 
no  chances  in  attempting  extirpation  without  the  preliminary  anus. 

Finally,  the  choice  of  method  in  such  cases  should  be  influenced 
very  largely  by  the  probable  results  of  each  as  derived  from  the  observa- 
tion of  a  large  number  of  cases.  The  following  table,  gathered  from 
a  collection  of  1,578  cases  of  extirpation  of  the  rectum  and  sigmoid, 
indicates  in  a  very  positive  manner  the  probable  results  which  may  be 
expected  from  each  procedure: 

TaUe 


Method. 

JiTuinber  of  cases. 

Deaths. 

MortaUty.' 

Sacral 

913 

569 

49 

32 

23 

2 

211 

76 

18 

9 

3 

2 

23.1  per  cent. 
13.5 

Perineal 

Abdominal 

36.7 

Combined 

40  9 

Vaginal  

14  3 

Anal 

100 

Total 

1,578 

319 

20 . 2  per  cent. 

From  these  statistics  one  is  forced  to  the  conclusion  that,  where  the 
location  and  extent  of  the  neoplasm  warrant  it,  the  perineal  operation 


858  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

should  be  the  method  of  choice.  In  women  the  vaginal  method  would 
seem  to  have  many  advantages,  but  in  a  closer  examination  of  the 
statistics  the  curious  fact  appears  that  in  them  the  abdominal  and  com- 
bined operations  have  given  almost  as  low  a  mortality  as  the  vaginal. 
In  18  cases  of  the  abdominal  and  combined  operations  in  women  there 
were  3  deaths.  For  some  unknown  reason  they  appear  to  stand  peri- 
toneal invasion  better  than  men.  In  Quenu's  collection  of  16  cases 
operated  upon  by  the  combined  method,  there  were  8  women  and  8  men. 
Of  the  8  women,  7  recovered  and  1  died;  of  the  men,  7  died  and  1 
recovered,  notwithstanding  the  fact  that  there  appeared  to  be  no  great 
disparity  in  the  gravity  of  the  cases  before  operation.  From  these  ex- 
periences one  must  be  discouraged  from  the  application  of  the  abdom- 
inal or  combined  methods  in  men,  whereas  the  results  in  women  are 
comparatively  satisfactory. 

In  small  isolated  epitheliomas  or  villous  tumors  in  the  lower  end  of 
the  anus,  one  of  two  methods  may  be  employed.  The  anus  may  be  split 
posteriorly  and  the  growth  excised,  if  it  be  low  enough  down  to  be 
reached  by  this  method.  The  edges  of  the  wound  from  which  the  tumor 
is  removed  should  be  carefully  sutured  together,  but  the  posterior  anal 
incision  should  be  left  open  in  order  to  secure  perfect  drainage  from 
the  parts.  Where  the  growth  is  too  high  up  to  be  reached  and  manipu- 
lated in  this  way,  one  may  approach  it  by  the  sacro-coccygeal  route, 
open  the  intestine  posteriorly,  excise  the  tumor,  and  close  the  wounds 
in  the  gut.  The  superficial  portion  of  the  wound  through  the  skin 
and  cellular  tissue,  however,  should  be  left  open  for  drainage  in  case 
infection  and  sepsis  should  occur.  The  author  has  little  sympathy  with 
either  of  these  operations.  In  his  experience  limited  excision  of  car- 
cinomatous growths  has  always  been  followed  by  a  rapid  recurrence 
either  necessitating  secondary  operation  or  ending  fatally  before  any 
relief  could  be  rendered.  Wide  extirpation  of  all  malignant  growths  is 
advisable  when  feasible;  otherwise  palliative  treatment,  as  has  been  de- 
scribed above,  must  be  employed. 

The  author's  experience  with  colotomy  in  these  cases  has  been  singu- 
larly unfortunate.  In  only  one  instance  of  20  operations  done  by  him- 
self, and  many  others  seen  after  operation  by  others,  has  the  life  of  the 
patient  been  prolonged  more  than  twelve  months.  In  a  number  of  cases 
in  which  no  operative  interference  has  been  employed,  he  has  seen  the 
patient  survive  from  one  to  three  years  in  comparative  comfort  through 
the  persistent  application  of  palliative  methods.  He  therefore  believes 
that  in  the  large  majority  of  inoperable  cases  just  as  much  comfort  and 
prolongation  of  life  can  be  obtained  by  these  methods  as  by  the  estab- 
lishment of  an  artificial  anus. 


CHAPTEE    XXI 

COL  OSTOMY— COL  0  TOMY—AB  TIFICIAL  ANUS 

The  old  term  colotomy  has  in  recent  years  been  superseded  by  the 
term  colostomy,  which  more  properly  describes  an  artificial  anus  or  open- 
ing in  the  colon,  being  derived  from  the  two  Greek  words  kwXov,  colon, 
and  a-TOfxa,  a  mouth  or  aperture.  When  the  artificial  opening  is  made 
in  the  small  intestine  it  is  spoken  of  as  enterostomy.  Petit,  to  whom 
we  are  indebted  for  the  term  colostomy,  suggested  (Union  medical,  1886, 
p.  577)  that  its  application  be  limited  to  permanent  artificial  anus,  and 
the  word  colotomy  should  be  employed  to  describe  the  temporary  variety. 
Aside  from  the  fact  that  there  is  no  warrant  in  ethnology  for  such  a 
distinction,  it  would  be  very  confusing,  for  the  term  colotomy  has  been 
employed  in  medical  literature  for  the  past  two  centuries  to  describe 
artificial  ani  both  temporary  and  permanent.  In  this  work,  therefore, 
the  two  terms  are  used  as  synonyms,  and  the  qualifying  adjectives  te^n- 
porary  and  permanent  are  em^Dloyed  as  the  occasion  may  require. 

Fortunately  there  are  very  few  conditions  in  which  a  permanent  arti- 
ficial anus  is  required.  Temporary  colostomy,  however,  is  employed 
more  and  more  frequently  in  the  treatment  of  inflammatory  conditions 
of  the  rectum,  sigmoid,  and  colon,  as  a  preliminary  operation  to  extir- 
pations and  resections  of  the  lower  end  of  the  intestinal  canal,  in  im- 
perforate ani,  in  complicated  fistulas  between  the  intestine  and  urinary 
organs,  in  certain  types  of  prolapse,  and  in  strictures  of  the  sigmoid 
flexure.  The  permanent  artificial  anus  is  employed  in  inoperable  stric- 
tures and  neoplasms  of  the  intestinal  tract,  in  cases  in  which  it  is 
impossible  to  reestablish  the  intestinal  canal  after  resection  of  the  dis- 
eased portions,  and  where  the  sphincters  and  entire  anus  have  been 
removed  in  amputating  the  rectum  for  malignant  disease.  Some  sur- 
geons prefer  to  establish  a  permanent  artificial  anus  in  all  cases  of 
malignant  disease  of  the  sigmoid  and  rectmn  whether  extirpation  is 
done  or  not.  The  author  has  expressed  his  disapproval  of  this  course. 
As  a  temporary  measure,  however,  to  divert  the  fa?cal  current  during 
extensive  operations  upon  the  intestine  below,  or  in  the  treatment  of 
conditions  heretofore  mentioned,  there  is  no  more  beneficent  or  useful 

859 


860  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

procedure.  This  side-tracking  of  the  fa'cal  cui-rent  was  first  suggested 
by  Pollosson  (Lyon  med.,  1884,  t.  xlvi,  i)p.  G7-T5),  and  i)ut  into  [)rae- 
tical  application  l)y  Schede  in  1887  (Deutsche  med.  Wochensclir.,  Leipz. 
u.  Berl.,  1887,  Ikl.  xiii,  S.  1048);  it  marks  the  dividing  line  between 
temporary  and  permanent  colostomy.  Up  to  this  time  all  artificial  ani 
had  been  made  with  the  view  to  establish  a  permanent  exit  for  the 
intestinal  contents,  and  every  surgical  effort  was  exerted  to  make  this 
outlet  effectual  so  as  to  prevent  the  escape  of  faecal  matter  into  the 
gut  below,  and  at  the  same  time  to  obtain,  if  possible,  a  certain  amount 
of  sphincteric  control. 

Since  then,  however,  surgeons  have  realized  the  fact  that  when  the 
artificial  anus  has  served  its  purpose  and  the  condition  for  which  it 
was  made  has  disappeared,  it  is  desirable  to  close  the  aperture,  and  to 
do  so  with  as  little  danger  to  the  patient  as  possible.  The  trend  of 
surgical  experiments  in  this  line,  therefore,  has  been  to  establish  a 
method  for  temporary  colostomy  which  will  be  effectual  as  long  as  it 
is  necessary,  and  in  which  the  aperture  can  be  closed  when  advisable 
without  any  particular  danger  to  the  patient. 

In  the  older  operations  the  closure  of  the  artificial  anus  necessi- 
tated enterotomy  or  resection  of  that  portion  of  the  colon  or  sigmoid 
involved  in  making  the  colostomy.  This  procedure,  as  is  well  known, 
proved  to  be  more  fatal  than  the  original  operation;  therefore  most 
surgeons  hesitated  to  recommend  colostomy  except  in  incurable  condi- 
tions. Happily  it  has  been  demonstrated  recently  that  a  temporary 
colostomy  may  be  made  in  such  a  manner  that  the  artificial  anus  can 
be  closed  when  it  has  survived  its  usefulness  without  opening  the  peri- 
toneal cavity  or  resecting  any  portion  of  the  gut.  This  fact  has  widened 
the  field  of  usefulness  of  the  operation,  induced  surgeons  to  employ  it, 
and  made  patients  willing  to  submit  to  its  inconveniences  for  a  time 
through  the  assurance  that  the  normal  channel  could  be  restored  when- 
ever the  condition  of  the  parts  below  warranted  it. 

In  works  on  general  surgery  two  types  of  colostomy  are  described — 
the  lumbar  and  the  inguinal.  The  term  abdominal  is  preferable  to 
inguinal  because  the  artificial  anus  is  frequently  made  elsewdiere  than 
in  the  inguinal  region,  as,  for  example,  in  the  operations  of  Finet  and 
Witzel,  and  in  colostomy  in  the  ascending  colon. 

Lumbar  colostomy  is  almost  an  obsolete  operation.  It  was  originally 
advocated  upon  the  ground  that  the  colon  could  be  reached  from  behind 
without  invasion  of  the  peritoneal  cavity.  Before  the  days  of  aseptic 
surgery  this  was  a  great  desideratum,  and  in  the  cases  in  which  it  was 
possible  no  doubt  contributed  largely  to  the  low  mortality  in  this  opera- 
tion. It  has  been  proved  by  .Vllingham  (op.  cit.,  p.  421)  that  in  the 
majority  of  cases  it  is '  impossible  to  open  the  colon  through  this  route 


COLOSTOMY— COLOTOMY— ARTIFICIAL  ANUS  861 

without  wounding  the  peritonaeum.  In  certain  instances  in  which 
there  is  no  mesentery  it  can  be  done;  in  others  in  whicli  tlie  mesentery 
is  short  its  folds  may  be  separated  and  tlie  gut  reached  witliout  ac- 
tually penetrating  the  peritoneal  cavity,  but  this  is  a  very  difficult  pro- 
cedure; while  in  those  with  long  mesenteries  it  is  quite  as  impossible  to 
reach  the  colon  through  the  lumbar  incision  as  through  the  abdominal 
without  invading  the  peritoneal  cavity.  The  difficulties  of  the  operation, 
the  fact  that  the  anus  Avas  inconveniently  placed  for  the  exercise  of 
proper  care  without  assistance,  the  peculiar  complications  which  one  was 
accustomed  to  meet  with  on  account  of  displacements  of  the  colon,  and 
abnormalities  in  the  kidney  or  ureter,  and  the  almost  insuperable  obsta- 
cles to  closure  of  the  artificial  anus  made  by  this  operation,  were  recog- 
nized by  surgeons  in  general,  but  these  were  thought  to  be  compensated 
for  by  avoidance  of  injury;  to  the  peritongeum.  This  dread  of  entering 
the  peritoneal  cavity,  sometimes  described  as  "  false,"  was  only  too  well 
founded  in  the  days  of  Amussat,  Callisen,  and  their  followers.  With 
the  advent  of  aseptic  surgery,  however,  it  has  disappeared,  and  with 
it  the  operation  of  lumbar  colostomy  has  almost  been  discarded  from 
surgical  practice.  It  is  an  operation  still  useful,  however,  in  certain 
conditions,  such  as  incurable  diseases  of  the  sigmoid  and  descending- 
colon,  in  which  the  ordinary  inguinal  anus  would  be  below  the  site  of 
the  disease,  and  also  in  cases  of  great  distention  of  the  intestines,  for 
in  such  eases  it  is  sometimes  easier  to  find  the  colon  by  this  route  than 
by  abdominal  incision.  It  is  an  operation  which  will  always  have  a  cer- 
tain field  of  usefulness,  and  therefore  merits  description. 

It  has  been  claimed  that  the  mortality  from  this  operation  is  less 
than  that  from  inguinal  colotomy.  Before  describing  the  methods, 
therefore,  let  us  look  into  this  phase  of  the  subject  and  determine 
somewhat  definitely  what  are  the  chances  of  death  in  these  two  opera- 
tions. 

Mortality  from  Colostomy. — In  discussing  this  question  one  must  not 
confound  the  mortality  from  operation  with  that  from  the  disease  for 
which  the  operation  is  done.  Many  patients  in  whom  colostomy  has 
been  performed  have  been  in  extremis  at  the  time  of  operation,  and  have 
died  from  the  disease  and  not  from  the  surgical  procedure.  Bryant, 
therefore,  in  discussing  the  mortality  in  lumbar  colotomy,  divides  his 
cases  intf)  urgent  and  non-urgent  ones.  Of  the  former  he  tabulates  100 
cases,  of  which  45  died  within  one  month.  He  does  not  give  the  cause 
of  death,  nor  does  he  state  in  how  many  it  could  be  attributed  to  the 
operation.  But  when  it  is  recalled  that  45  per  cent  died  within  one 
month,  it  is  fair  to  presume  that  the  immediate  mortality  was  not  in- 
considerable. Of  the  70  non-urgent  cases  which  he  reports,  none  died 
within  the  first  month.     There  can  be  no  more  forcible  argument  in 


862 


THE   ANUS,   RECTUM.   AND   PELVIC   COLON 


favor  of  early  c-olustuiuy  in  iiiuligiiant  disoase  than  these  figures  of  the 
great  English  surgeon.  This  record  is  the  more  remarkable  from  the 
fact  that  many  of  the  operations  were  done  with  the  crudest  aseptic 
precautions. 

Croley  (Transactions  of  the  Academy  of  ]\Iedicine,  Ireland,  1896, 
p.  147)  has  reported  18  cases  of  lumbar  colotomy  with  no  deaths,  the 
patients  all  living  from  a  few  months  to  over  two  years  after  operation. 
On  the  other  hand,  Wheeler  {ihid.,  p.  133)  estimated  the  mortality  from 
this  operation  in  urgent  and  non-urgent  cases  at  25  per  cent.  His  sta- 
tistics, however,  were  drawn  from  the  compilations  of  Batt  and  others 
made  before  the  days  of  aseptic  surgery.  The  lumbar  operation  is  so 
seldom  performed  at  the  present  day  that  it  is  almost  impossible  to  give 
any  definite  figures  with  regard  to  its  mortality  under  modern  surgical 
precautions;  but  from  the  figures  which  the  author  has  been  able  to  ob- 
tain, it  is  estimated  that  the  death-rate  in  a  consecutive  number  of 
cases,  as  they  come,  will  not  fall  short  of  12  per  cent. 

In  inguinal  colostomy  it  is  much  easier  to  arrive  at  some  conclusion 
with  regard  to  the  mortality.  Kelsey  says:  "  Given  100  cases  seen  early 
and  in  good  condition,  it  would  be  easy  to  escape  any  mortality  from 
the  operation  whatever.  On  the  other  hand,  taking  the  same  number 
of  cases  as  they  present  themselves  from  time  to  time,  there  would 
probably  be  a  considerable  death-rate."  The  statistics  of  Batt  (Amer. 
Jour.  Med.  Science,  October,  1884,  p.  423),  in  which  a  mortality  of 
31.8  per  cent  for  lumbar  and  53.1  per  cent  for  inguinal  colostomy  is 
given,  must  be  ignored  at  the  present  day.  These  figures  were  drawn 
from  operations  done  before  the  advent  of  aseptic  surgery,  and  at  times 
when  the  procedure  was  so  unfavorably  considered  by  surgeons  that  it 
was  put  off  until  the  patients  were  practically  moribund.  They  do  not 
represent  in  any  way  the  results  from  either  of  these  operations  at  the 
present  time.  Under  modern  aseptic  precautions,  and  in  the  hands  of 
competent  operators,  inguinal  colotomy  is  followed  by  a  comparatively 
low  mortality.    The  following  table  illustrates  this  fact  most  forcibly: 


Table 


Operator. 

Xuniber  of  cases?. 

Deaths. 

Allingham     

68 
65 
27 
9 
16 
22 
24 
24 

2 

Reeves        

0 

Cripps     

1 

Wheeler      

1 

Edwards       .        

1 

Goodsall                 

0 

Author 

1 

Miscellaneous    , 

2 

Total 

255 

,s 

COLOSTOMY— COLOTOMY— ARTIFICIAL  ANUS  863 

In  this  list  we  have  255  cases  with  8  deaths,  a  mortality  of  3.1  per 
cent. 

It  is  reasonable  to  supjjose  that  the  average  run  of  cases  subjected 
to  the  abdominal  operation  are  equally  as  grave  as  those  in  which  the 
lumbar  method  is  employed,  and,  assuming  such  to  be  the  case,  it  ap- 
pears very  clear  that  the  figures  are  greatly  in  favor  of  inguinal  colos- 
tomy. [N'evertheless  the  operation  is  not  without  its  hazard,  and  it 
should  not  be  undertaken  without  a  due  appreciation  thereof  and  a 
frank  statement  of  the  possibilities  in  the  case  to  the  patient  and  his 
friends.  It  is  an  operation  that  requires  good  judgment  to  determine 
its  necessity,  an  accurate  knowledge  of  the  parts  involved,  and  a  most 
delicate  manipulative  skill  in  its  performance.  As  Mathews  says,  too 
many  men  attempt  it  who  are  inexperienced  in  surgical  technique,  and 
without  mature  judgment  in  the  selection  of  cases. 

In  emergency  cases,  such  as  complete  obstruction,  delay  in  obtaining 
the  services  of  an  expert  surgeon  will  often  jeopardize  the  patient's 
life.  It  is  necessary,  therefore,  that  every  practitioner  should  be  pre- 
pared to  perform  this  operation  upon  a  moment's  notice.  A  certain 
number  of  fatalities  will,  of  course,  result  from  inexperience  or  lack  of 
aseptic  surroundings,  but  this  number  will  be  more  than  counterbalanced 
by  the  lives  saved  which  would  otherwise  be  lost  through  delay  or 
transporting  the  patient  to  a  hospital. 

In  operations  of  election,  however,  especially  where  temporary  colot- 
omy  is  proposed,  there  is  little  excuse  for  any  fatalities.  Accidents  have 
occurred  in  this  operation  resulting  in  death  several  days  afterward, 
but  it  would  appear  that  these  were  all  avoidable.  Were  this  not  the 
case  one  would  hesitate  to  advise  the  operation  in  such  conditions  as 
mucous  colitis,  rectal  ulceration,  and  complicated  fistula,  for  these  con- 
ditions, while  annoying,  are  not  usually  fatal. 

The  conclusions  in  regard  to  the  mortality  from  abdominal  colostomy 
are  deduced  from  the  statistics  of  expert  operators.  The  figures  do 
not  represent  accurately  the  results  of  all  colostomies  done  everywhere, 
but  they  do  represent  what  can  be  accomplished  by  those  perfectly 
familiar  with  the  method. 

Lumbar  Colostomy. — This  procedure,  generally  known  as  Amussat's 
operation,  was  first  proposed  by  Callisen  in  1796,  who  employed  a  per- 
pendicular incision  just  in  front  of  the  left  quadratus  lumborum  mus- 
cle. Amussat  modified  the  operation  by  making  a  transverse  incision 
in  the  loin,  and  extended  its  application  to  the  colon  on  the  right  side. 
Sir  Thomas  Bryant  further  modified  the  operation  by  employing  an 
oblique  incision  just  below  the  border  of  the  floating  ribs,  thus  reaching 
the  colon  at  a  higher  level  than  was  attempted  by  Callisen  or  Amussat. 
In  all  these  operations  the  lumbar  muscles  were  incised,  but  recently 


864 


THE  ANUS,  RECTUM,   AXD   PELVIC  COLON 


Fig.  30<i. — Line  of  Ixcisios  ix  Limbar  Colostomt,    (^Bryant.) 


Operators  have  been  acciistoiued  to  separate  them  hy  blunt  dissection 
instead  of  cutting,  after  the  manner  advised  by  Howse.  The  method 
of  Bryant,  who  has  had  the  Largest  experience  in  this  operation,  is  as 
follows: 

The  patient  is  laid  upon  the  opposite  side  from  which  the  colostomy 
is  to  be  done,  and  a  firm  pillow  or  sand-bag  is  placed  under  the  loin  in 
order  to  make  the  flank  prominent,  and  being  turned  somewhat  upon 

his  face,  the  anterior 
border  of  the  quadratus 
lumborum  can  be  dis- 
tinctly felt.  An  inci- 
sion is  made  just  below 
the  border  of  the  -last 
rib  (Fig.  300),  begin- 
ning an  inch  and  a  half 
back  of  the  anterior  su- 
perior spine,  and  ex- 
tending downward  and 
forward  parallel  with 
the  crest  of  the  ilium 
for  about  5  inches. 
Having  incised  the  skin 
and  cellular  tissue,  one 
should  separate  the 
fibers  of  the  external 
oblique  and  latissimus 
dorsi  muscles,  holding 
them  apart  with  broad 
retractors;  below  these 
one  comes  upon  the  in- 
ternal oblique  muscle, 
which  should  be  sepa- 
rated in  like  manner  by 
dull  dissection,  thus  ex- 
posing the  lumbar  fas- 
cia, the  fibers  of  which 
run  transversely  and  may  be  separated  or  cut.  The  external  border 
of  the  quadratus  lumborum  will  thus  be  exposed,  together  with 
the  transversalis  fascia.  At  this  point  one  should  stop  and  ligate  all 
bleeding  vessels  in  order  to  get  rid  of  any  hemostatic  forceps  in  the 
wound.  With  broad  retractors  holding  the  tissues  apart  (Fig.  301),  the 
transversalis  fascia  is  freely  incised,  and  beneath  it  one  enters  the  bed  of 
subserous  fat  in  which  the  kidney  is  embedded  and  in  front  of  which 


YiG.  Sul. — Llmbae  CuLOoToiiy.     (.Bryant.) 

Transversalis  fascia  incised  and  subseroas  fat  pushed  aside,  ex- 
posing colon  above  and  quadratus-lumborum  muscle  below. 


COLOSTOMY— COLOTOMY— ARTIFICIAL   ANUS 


865 


lies  tlie  colon.  This  fat  should  be  eautiousl}-  torn  ajDart  b}^  the  fingers 
or  a  blunt  instrument  in  order  to  avoid  wounding  the  kidney  or  ureter, 
which  are  sometimes  abnormally  placed.  The  kidney  should  be  located 
during  this  blunt  dissection,  as,  according  to  Bryant,  the  colon  always 
lies  just  in  front  of  its  lower  border.  In  some  eases  in  which  there  is 
a  small  amount  of  fat,  or  when  the  colon  is  greatly  distended,  the  latter 
will  come  into  view  upon  incising  the  transversalis  fascia.  In  other 
cases,  where  the  fat  is  abundant  and  the  gut  collapsed,  it  is  quite  diffi- 
cult to  find  the  colon.  It  is  usually  searched  for  too  far  away  from  the 
spine.  It  is  sometimes  said  that  the  longitudinal  fibers  of  the  gut  and 
appendices  epiploicae  can  be  seen  at  this  point,  thus  distinguishing  the 
colon  from  the  small  intestine;  but  Allingham  has  sho\\Ti  this  to  be 
impossible  unless  the  peritoneal  cavity  is  opened.  All  that  one  needs 
to  guide  him  is  the  fact  that  if  any  gut  at  all  is  reached  without  enter- 
ing the  peritoneal  cav- 
ity, it  must  be  the  colon. 
Whether  the  latter  can 
be  reached  without  en- 
tering the  j)eritoneal 
cavity  or  not  depends 
upon  the  length  of  the 
mesentery. 

Assuming  that  the 
latter  is  short,  the  next 
step  in  the  operation 
consists  in  rolling  the 
gut  slightly  forward  and 
then  passing  a  silk  liga- 
ture through  the  skin,  then  through  the  gut,  embracing  about  ^  of 
its  circumference,  and  even  through  the  skin  on  the  opposite  side  of 
the  wound.  The  gut  is  now  incised  longitudinally,  and  the  loops  of  the 
sutures  passed  through  it  are  caught,  drawn  out  through  the  wound, 
and  cut  in  the  middle;  the  ends  are  then  tied  to  those  passed  through 
the  skin  on  their  respective  sides.  In  order  to  avoid  soiling  the 
wound  with  escaping  fgeces,  the  gut  should  be  caught  with  forceps 
and  dragged  outside,  if  possible,  gauze  being  packed  on  each  side  of  it 
before  the  intestinal  incision  is  made.  The  packing  should  be  kept  in 
place  until  the  first  gush  of  fgeces  and  gas  has  subsided;  then  the  canal 
should  be  packed  with  gauze  to  prevent  any  further  escape,  the  parts 
washed  with  sterilized  solution,  the  gauze  packing  around  the  gut  re- 
moved, and  the  edges  of  the  skin  and  intestinal  wounds  should  be  sutured 
together  by  close  interrupted  silk  sutures.  Sometimes  there  is  no  ftecal 
discharge  at  all  for  days  after  the  operation. 
55 


Sitj. — Llji.l].  t  )L<icT()ji_i    I     jiLi.lL..      lilryaiit.) 


866  THE  AXUS,   RECTUM,   AND   PELVIC  COLON 

In  cases  of  distention,  failure  of  gas  to  escape  would  indicate  that 
the  opening  had  been  made  below  the  point  of  obstruction,  and  that 
the  operation  would  be  of  no  avail. 

After  the  gut  has  been  fixed  in  position  (Fig.  302),  the  gauze  is  re- 
moved from  the  canal  and  the  parts  are  smeared  with  sterilized  vaseline 
or  cerate  in  order  to  prevent  the  iseees  irritating  the  skin  and  the  dress- 
ings sticking  to  the  edges  of  the  wound.  The  latter  is  then  dressed  with 
dry,  fluffy  gauze  covered  by  rubber  protective  held  in  position  by  a  firm 
abdominal  binder  or  adhesive  plaster.  The  patient  is  placed  on  his  back 
in  bed,  and  a  sufficient  amount  of  morphine  is  administered  hypoder- 
mically  to  overcome  nausea;  otherwise  no  opiate  should  be  administered, 
as  it  retards  the  peristaltic  action  of  the  intestine  and  prevents  the 
restoration  of  tone  in  the  bowels  which  have  been  overdistended  and 
partially  paralyzed.  The  stitches  should  be  removed  about  the  sixth 
day  and  the  patient  allowed  to  sit  up  at  the  end  of  ten  days  or  two  weeks. 

As  will  be  seen,  no  effort  is  made  at  first  to  establish  a  spur  which 
will  prevent  the  escape  of  faecal  matter  into  the  lower  segment  of  the 
bowel.  Several  methods  have  been  devised  to  accomplish  this.  One 
of  these  consists  in  drawing  the  deep  wall  of  the  gut  out  through  the 
opening  in  the  exposed  portion,  dissecting  off  the  mucous  membrane 
around  the  lower  opening  thus  formed,  and  suturing  the  freshened  sur- 
faces together,  thus  absolutely  occluding  the  inferior  segment  of  the 
gut.  A  simpler  method  consists  in  pulling  the  posterior  wall  forward 
and  passing  a  wire  suture  through  the  skin,  underneath  the  gut  and  out 
through  the  skin  on  the  opposite  side;  the  wire  being  drawn  taut  and 
fastened  by  shields  on  either  end  thus  holds  the  gut  well  out  of  the 
wound  and  produces  a  very  effectual  spur. 

In  cases  where  on  account  of  a  long  mesentery  the  colon  can  not 
be  reached  without  entering  the  peritoneal  cavity,  it  should  be  drawn 
out  of  the  lumbar  wound  and  fixed  by  sutures  or  a  supporting  rod  passed 
from  one  side  of  the  wound  to  the  other.  In  these  cases  some  hours 
should  elapse  before  the  intestine  is  opened,  if  the  condition  of  the  pa- 
tient will  allow.  Where  there  is  very  great  distention,  however,  the  gut 
may  be  packed  around  with  absorbent  gauze,  and  a  trocar  introduced 
to  allow  the  escape  of  gases.  After  this  has  been  accomplished,  the 
wound  made  by  the  trocar  should  be  closed  with  Lembert  sutures,  the 
gut  fijced  in  position,  and  opened  at  a  later  period. 

Inguinal  or  Abdominal  Colostomy. — It  is  now  nearly  two  himdred 
years  since  Littre  (Memoire  de  I'academie  des  sciences,  Paris,  vol.  x, 
p.  36)  first  proposed  to  make  an  artificial  anus  by  an  incision  in  the 
abdomen  ("  au  ventre  ").  His  advice  was  to  open  the  sigmoid  flexure 
for  the  relief  of  obstruction  below.  He  laid  no  particular  stress  upon 
the  point  of  incision,  and  does  not  appear  to  have  done  the  operation 


COLOSTOMY— COLOTOMV— ARTIFICIAL  ANUS  861 

upon  a  living  subject.  Pillore,  of  Rouen,  first  made  an  inguinal  anus 
for  complete  obstruction  due  to  cancer  of  the  rectum  in  1776  (Brit,  and 
For.  Med.  Eeyiew,  xviii,  p.  452).  In  this  case  the  opening  was  made 
in  the  cfecum  upon  the  right  side,  and  the  patient  lived  twenty-eight 
days,  finally  dying  from  causes  not  due  to  the  operation.  Following  him, 
Duboise  performed  the  operation  in  1783  for  imperforate  anus,  the  child 
dying  in  ten  days;  ten  years  later  Dinet^Med.  oper.  sabatier,  ii,  p.  336) 
attempted  the  procedure  for  a  like  cause  in  a  child  two  days  old.  This 
patient  lived  many  years.  In  1791:  Desault  operated  in  a  similar  case, 
but  without  success.  Thus  in  the  first  four  operations  by  the  abdominal 
method,  three  were  done  for  imperforate  ani  and  one  for  intestinal 
obstruction,  with  a  mortality  of  50  per  cent. 

Shortly  after  this  Fine,  of  Geneva  (Manuel  de  med.  pratique  de 
Louis  Adier  de  Geneve,  second  edit.,  1811),  made  an  artificial  anus  in  the 
transverse  colon  by  an  incision  through  the  rectus  muscle  just  above 
the  umbilicus.  Following  these,  Martland,  in  ISIL  (Edinburgh  Medical 
and  Surgical  Jour.,  1825,  p.  271),  Freer  in  1817,  and  Pring  in  1820 
(London  Med.  and  Physical  Jour.,  1821)  performed  the  operation,  mak- 
ing the  anus  in  the  sigmoid  flexure.  Up  to  this  time  no  effort  or  sug- 
gestion had  been  made  to  avoid  wounding  the  peritonfeuni.  Callisen 
does  not  even  seem  to  have  thought  of  this  when  he  proposed  the  left 
lumbar  operation,  "  because/'  as  he  says,  "  the  intestine  may  be  reached 
more  easily  in  this  place  than  above  in  the  iliac  region."  Xevertheless, 
the  fear  of  wounding  the  peritonaeum  grew,  and  when  Amussat  demon- 
strated that  he  could  open  the  colon  from  behind  without  entering  the 
peritoneal  cavity,  and  substantiated  his  claim  by  reporting  6  cases  with 
1  death  (Gaz.  med.  de  Paris,  1839,  ISTo.  1),  the  results  were  so  remarkable 
that  the  Littre  operation  immediately  fell  into  disuse  and  became  prac- 
tically obsolete  for  the  next  half  centur}-. 

Since  it  has  been  demonstrated,  however,  that  the  peritoneal  cavity 
can  be  opened  with  comparatively  little  danger  under  aseptic  precau- 
tions, the  tables  have  been  turned,  and  the  inguinal  or  abdominal  opera- 
tion is  now  almost  universally  employed.  The  advantages  which  it 
offers  are:  First,  it  is  more  easily  and  quickly  performed;  second,  there 
is  less  danger  of  infection  and  inflammation  in  the  wound  because  it  is 
shallower;  third,  it  furnishes  an  opportunity  for  abdominal  exploration 
which  is  of  the  greatest  importance  in  all  cases  in  which  an  artificial  anus 
is  necessary;  fourth,  the  site  at  which  the  anus  is  placed  makes  it  more 
convenient  and  comfortable  to  the  patient;  fifth,  the  difficulties  of 
closure  are  much  less  than  when  the  artificial  anus  is  in  the  lumbar 
region;  sixth,  the  mortality  is  lower  in  this  method  than  in  lumbar 
colostomy.  For  these  reasons  this  method  should  be  employed  except 
in  the  rare  instances  mentioned  above. 


868  THE  AXUS,  RECTUM,   AND  PELVIC  COLON 

Until  within  a  few  years,  inguinal  colostomy  was  employed  only  to 
overcome  or  prevent  intestinal  obstruction.  Eecently  it  has  been 
adopted  generally  as  a  means  of  treatment  in  various  conditions,  and 
as  a  preliminary  measure  to  extensive  operations  upon  the  lower  portions 
of  the  intestinal  canal.  It  is  also  being  done  much  earlier  and  more 
frequently  in  inoperable  cases  of  malignant  disease  of  the  rectum  and 
sigmoid,  since  it  has  been  shown  by  Witzel,  Baile}^,  Weir,  and  others  that 
the  artificial  anus  can  be  so  fashioned  that  the  patient  is  comparatively 
safe  from  involuntary  faecal  discharges.  There  are  therefore  two  distinct 
classes  in  which  it  is  employed:  First,  cases  in  which  the  disease  is  curable 
by  treatment  or  surgical  procedure,  and  in  ivhich  it  is  possible  to  reestablish 
the  normal  f cecal  canal;  second,  cases  in  which  the  disease  is  incurable,  or 
in  which,  the  diseased  portion  being  removed,  it  is  impossible  to  reestablish 
the  normal  canal. 

In  the  first  class,  when  an  artificial  anus  is  determined  upon,  it  is 
important  that  it  should  be  made  in  such  a  manner  that  it  can  be 
eventually  closed  with  the  least  possible  disturbance  and  danger  to  the 
patient.  In  the  second  class  the  anus  should  be  so  fashioned  that  it  can 
be  easily  attended  to  and  will  possess  the  greatest  amount  of  faecal  con- 
trol. In  the  early  application  of  this  operation,  when  it  was  only  per- 
formed for  incurable  conditions,  the  chief  effort  of  surgeons  was  to  pro- 
duce an  artificial  anus  w^hich  would  be  an  effectual  exit  for  faecal  material 
and  prevent  its  escape  into  the  lower  or  diseased  segment  of  the  gut. 
All  devices  and  improvements  in  the  operation  during  this  period  were 
directed  toward  the  formation  of  an  acute,  elevated  spur  between  the  two 
legs  of  the  loop  in  which  the  anus  was  made,  and  toward  the  prevention 
of  prolapse.  The  methods  of  Allingham,  Cripps,  Kelsey,  Bodine,  Maydl, 
and  Eeclus  were  all  directed  toward  these  ends.  On  the  other  hand, 
the  methods  of  Witzel,  Bailey,  Paul,  and  Weir  are  all  directed  toward 
the  formation  of  a  permanent  artificial  anus  that  will  possess  the  greatest 
amount  of  continence,  and  in  the  most  convenient  position  for  the 
patient.  The  former  are  adapted  to  temporary,  the  latter  to  permanent, 
colostomy.  The  discussion  of  this  subject,  therefore,  naturally  divides 
itself  into  that  of  the  temporary  and  permanent  methods. 

Temporary  Colostomy. — The  temporary  artificial  anus  consists  in  an 
opening  made  in  the  intestine  at  some  point  above  the  seat  of  disease 
for  the  purpose  of  turning  aside  the  fsecal  current  while  local  treatment 
or  some  operative  procedure  is  being  carried  out  upon  the  parts  below. 
The  site  at  which  this  opening  is  made  depends  upon  the  location  of  the 
disease  and  the  treatment  which  is  to  be  adopted.  If  the  latter  is  to  be 
local  medication,  the  artificial  anus  should  be  placed  as  close  to  the 
diseased  area  as  is  consistent  with  its  establishment  in  healthy  tissue;  if 
operative  procedures  are  to  follow,  it  should  be  placed  sufficiently  far 


COLOSTOMY— COLOTOMY— ARTIFICIAL  ANUS  869 

away  to  allow  the  greatest  freedom  to  the  surgeon  in  dealmg  with  the 
healthy  segment  of  the  gut  between  it  and  the  diseased  portion.  In 
other  words,  if  there  is  a  tumor  or  stricture  to  be  removed,  the  artificial 
anus  should  be  so  placed  that  it  will  not  interfere  with  the  manual 
performance  of  the  operation,  and  that  there  will  remain  sufficient 
healthy  intestine  below  it  through  which  to  reestablish  the  normal  faecal 
canal  if  such  is  possible.  Thus,  in  some  cases,  it  is  advisable  to  make 
the  artificial  anus  in  the  lower  portion  of  the  sigmoid,  in  some  in  the 
upper  portion,  and  in  still  others  in  the  transverse  or  ascending  colon. 

The  essentials  of  a  temporary  artificial  anus  are,  a  free  exit  for  faecal 
matter,  absolute  prevention  of  its  escape  into  the  gut  below,  and  facility 
of  closure  after  its  purposes  have  been  served.  The  latter  is  of  the 
utmost  importance,  for  if  the  closure  of  the  temjDorary  anus  is  more 
dangerous  than  the  operation  of  making  it,  or  even  than  that  for  which 
it  is  made  a  preliminary  procedure,  it  could  hardly  be  recommended 
to  patients  with  much  confidence.  It  is  necessary,  therefore,  in  making 
such  an  anus  to  have  clearly  in  view  its  ultimate  closure,  and  so  make 
it  that  this  may  be  comparatively  sure,  and  as  far  as  possible  free  from 
danger  to  life. 

The  Operation. — There  are  several  drff'erent  techniques  employed  in 
the  performance  of  this  operation.  Some  were  devised  especially  to 
form  an  effectual  spur,  others  to  prevent  prolapse,  and  still  others  with 
a  view  to  ultimate  closure. 

The  preparation  of  the  patient,  the  incision  and  the  opening  of  the 
abdomen  are  practically  the  same  in  all,  and  need  be  described  but  once. 
The  patient  should  be  prepared  as  for  laparotomy;  the  pubes  shotild  be 
shaved,  the  abdomen  scrubbed  with  green  soap  and  dressed  with  bichlor- 
ide gauze  the  night  before  the  operation.  The  bowels  should  be  moved 
by  a  laxative  the  day  previous,  and  by  an  enema  on  the  day  of  the 
procedure.  These  preparations  will  be  impossible  in  emergency  cases, 
and  in  such  one  must  content  himself  with  the  best  immediate  aseptic 
preparations  possible.  After  the  patient  is  ansesthetized,  the  abdomen 
should  be  thoroughly  scrubbed  with  tincture  of  green  soap,  then  with 
a  solution  of  bichloride  (1  to  2,000),  and  fitially  with  alcohol  95  per  cent. 
This  simple  aseptic  preparation,  if  thoroughly  carried  out,  is  as  effectual 
as  the  most  complicated  methods.  In  350  aseptic  cases  in  which  it  was 
employed  in  the  Almshouse  and  Workhouse  hospitals  in  the  years 
1898  and  1899,  only  3  cases  of  infection  occurred — one  due  to  escape 
of  urine  into  the  wound,  one  to  the  use  of  old  catgut  by  mistake,  and 
the  third  to  the  patient's  having  got  out  of  bed  and  disarranged  the 
dressings  a  few  lioiirs  after  the  operation.  With  such  an  experience, 
the  author  is  convinced  that  no  more  elaborate  preparation  of  the 
patient  is  necessary. 


870 


THE  ANUS,   RECTUM,   AND  PELVIC  COLON 


The  abdomen  having  been  thus  prepared,  is  covered  with  sterilized 
towels  or  sheets  except  at  the  immediate  operative  field.  If  the  artificial 
anus  is  to  be  made  in  the  left  inguinal  region,  an  incision  should  be 
made  through  the  skin  in  a  line  with  the  fibers  of  the  external  oblique 

muscle;  it  should  be- 
gin 1  inch  above  and 
li  inch  inside  of  the 
anterior  superior  spine; 
its  length  should  be  2^ 
to  3  inches  or  longer 
in  fat  people,  and  it 
should  be  carried 
through  the  skin  and 
superficial  fascia  to  the 
fibers  of  the  external 
oblique  muscle  (Fig. 
303).  Some  operators 
divide  the  entire  wall 
of  the  abdomen  by 
clean  incision.  It  is 
preferable,  however,  to 
separate  the  fibers  of 
the  muscles  in  each 
layer  by  dull  instru- 
ments, dragging  them 
apart  with  retractors, 
and  thus  preserving 
their  functional  action. 
By  this  method  the  ex- 
ternal oblique  is  first 
separated  in  one  line,  the  internal  oblique  in  another,  and  the  fascia 
transversalis  then  comes  into  view  (Fig.  304).  At  this  point  one 
should  tie  all  bleeding  vessels,  and  thoroughly  dry  the  wound  in  order 
to  prevent  any  oozing  of  blood  into  the  peritoneal  cavity.  The  fascia 
transversalis  is  then  incised  in  a  line  with  Poupart's  ligament  to  the 
extent  of  about  2  inches;  this  brings  the  peritonaeum  into  view,  and 
it  should  be  incised  in  the  same  line,  its  edges  being  caught  by  artery 
clamps  and  drawn  up  through  the  wound  to  prevent  its  being  stripped 
off  from  the  abdominal  wall  during  the  examination.  The  patient 
should  then  be  placed  in  the  Trendelenburg  posture  in  order  to  free 
the  pelvis,  if  possible,  from  the  loops  of  small  intestine  and  omentum. 

The  incision  should  be  made  large  enough  to  permit  the  introduc- 
tion of  the  hand,  so  that  it  will  be  possible  to  explore  carefully  the 


Fig.  303. — Incision  in  Inguinal  Colostomy. 

Skin  and  subcutaneous  fat  drawn  aside,  e.xposing  external 
oblique  muscle. 


COLOSTOMY— COLOTOMY— ARTIFICIAL  ANUS 


871 


pelvic  and  abdominal  cavities  before  attempting  to  find  the  sigmoid. 
One  can  never  say  exactly  at  what  point  the  artificial  anus  should  be 
made  until  such  an  exploration  has  been  carried  out.  Even  in  cases 
with  great  distention  this  examination  is  of  the  utmost  importance, 
because  it  enables  one  sometimes  to  find  the  collapsed  portion  of  the 
gut  below  the  obstruction,  and  thus  determine  the  exact  site  of  the 
latter.  After  this  exploration  has  been  made,  with  the  hand  well  down 
in  the  pelvis,  one  may  trace  the  rectum  upward,  and  thus  without  any 
diificulty  secure  the  lower  loop  of  the  sigmoid  flexure  and  drag  it  out 
of  the  wound,  being  absolutely  certain  as  to  which  is  the  superior  and 
which  is  the  inferior  segment.  The  sigmoid  and  colon  are  recognized 
by  the  longitudinal  muscular  bands  and  by  the  attachment  of  the 
appendices  epiploic^.  'WTiile  such  extensive  exploration  adds  to  the 
possibility  of  peritonitis,  this  danger  is  more  than  compensated  for  by 
the  exact  knowledge  which  is  acquired  of  the  parts  that  are  to  be  dealt 
with.  Most  operators  advise  introducing  the  forefinger  through  the 
abdominal  wound,  and  search- 
ing for  the  sigmoid  in  the  iliac 
fossa  before  exploring  the  ab- 
domen, but  this  is  not  so  sat- 
isfactory as  exploration  with 
the  whole  hand. 

Fixation  of  the  Gut. — After 
the  sigmoid  is  found  and  it  has 
been  determined  which  part  of 
it  is  to  be  fixed  in  the  abdom- 
inal wound,  the  operation  may 
proceed  in  several  different 
ways. 

Some  surgeons  suture  the 
parietal  peritoneum  to  the 
edges  of  the  skin  wound,  hold- 
ing that  union  between  this 
and  the  peritoneal  layer  of  the 
gut  will  be  more  rapid  than 
that  between  the  intestine  and 
freshly  cut  surfaces.     Reclus, 

however,  has  shown  that  this  is  a  useless  waste  of  time,  as  it  does  not 
hasten  union  in  the  least,  and  produces  a  weaker  adhesion  of  the  gut 
to  the  abdominal  walls.  The  author  has  verified  this  claim,  and  in  his 
last  15  cases  has  not  sutured  these  tissues  together.  The  fixation  of 
the  gut  in  the  wound  and  the  method  of  opening  it  are  the  points  on 
which  operators  essentially  differ. 


Fig.  S04 — Inguinal  Colostomy. 

Exposure  and  separation  of  the  internal  oblique 
muscle. 


872 


THE  ANUS,   RECTUM,   AND   PELVIC  COLON 


Fig.  305.— Inguinal  Colostomy  (Cripps's  method). 
a  a,  tractiou  loops  ;  b  b,  sutures  meeting  peritonanun  and  skin. 


Cripps's  Method. — After  the  sigmoid  has  been  found,  it  is  dragged  out 
of  the  wound  until  the  upper  segment  is  taut,  the  lower  being  pushed 
back  in  the  abdomen;  this  is  done  in  order  to  prevent  subsequent  prolapse. 
In  the  loop  thus  brought  out  of  the  wound  two  provisional  ligatures 
are  passed  through  the  longitudinal  muscular  band  opposite  the  mesen- 
tery. The  ends  of  these  ligatures  are  left  long,  and  are  used  to  steady 
the  bowel  during  its  subsequent  stitching  to  the  abdominal  wall;  they 
also  act  as  guides  in  opening  the  intestine.     The  loop  is  now  dropped 

back  in  the  ab- 
6 ,  ';    /  .       I  ,n.  domen  while  the 

parietal  perito- 
naeum is  sutured 
to  the  skin;  it  is 
then  drawn  up 
into  the  wound 
again,  and,  while 
an  assistant  holds 
the  long  liga- 
tures taut,  it  is 
fixed  in  position 
by  7  or  8  fine  silk 
sutures,  which 
pass  through  its 
peritoneal  and 
muscular  walls, 
and  then  through 
the  edges  of  the 
peritonaeum  and 
skin  (Fig.  305). 
The  sutures  at 
the  angles  of  the 
wound  pass  first 
through  the  skin 
and  peritonaeum, 
then  through  the 

peritoneal  and  muscular  layers  of  the  gut,  and  out  through  the 
peritona?um  and  skin  upon  the  opposite  side.  The  sutures  in  the 
gut  are  introduced  in  the  longitudinal  band  on  one  side  and  along 
the  border  of  the  mesentery  on  the  other;  about  two-thirds  of  the 
circumference  of  the  gut  is  thus  secured  outside  of  the  wound  (Fig. 
306).  Unless  the  case  is  very  urgent,  the  gut  is  not  opened  until  several 
hours,  or  even  two  days,  after  the  operation.  The  wound  is  dressed  by 
being  smeared  with  sterilized  vaseline  and  covered  with  thin  oiled  silk 


Fig.  306.- 


-Inguinal  Colostomy  (Cripps's  method). 
Final  sutures  in  place. 


COLOSTOMY— COLOTOMY— ARTIFICIAL  ANUS  873 

or  rubber  protective  tissue,  over  which  is  placed  a  thick  mass  of  gauze 
or  cotton  held  in  position  by  adhesive  plaster  or  an  abdominal  bandage. 
The  vaseline  and  rubber  tissue  prevent  adhesion  of  the  gut  to  the 
gauze  dressings,  so  that  they  may  be  easily  removed  whenever  it 
is  thought  wise  to  open  the  gut.  When  this  period  arrives,  the  gut 
is  incised  longitudinally  between  the  two  long  ligatures  which  have 
been  left  in  position,  and  its  edges  above  the  level  of  the  skin  are 
trimmed  away. 

AUingliam's  Metliod. — After  the  abdomen  is  opened  the  parietal  peri- 
tonseum  is  sutured  at  once  to  the  skin  around  the  edges  of  the  wound; 
the  sigmoid  is  then  found  and  dragged  out  of  the  abdomen  until  both 
the  upper  and  lower  legs  of  the  loop  are  drawn  taut.  A  suture  of 
carbolized  silk  is  then  passed  through  the  skin  and  peritonaeum  on  the 
outer  side  of  the  wound,  then  through  the  mesentery,  back  again 
through  the  latter,  and  then  tied  to  the  end  left  outside  of  the  skin. 
The  mesentery  is  thus  held  in  apposition  with  the  parietal  peritonEeum, 
and  all  of  the  sigmoid  which  can  be  drawn  through  the  abdominal 
wound  is  held  outside  of  the  abdomen.  The  edges  of  the  wound  are 
then  sutured  to  the  gut;  the  greater  the  distention  the  more  sutures 
will  be  required  to  prevent  hernia  of  the  small  intestines  through  the 
wound.  The  gut  is  not  opened  for  some  hours,  or  even  three  days  if 
the  symptoms  are  not  urgent.  It  is  then  incised  longitudinally,  and 
after  the  bowels  are  once  thoroughly  emptied  through  this  opening  a 
specially  devised  clamp  is  applied  which,  being  tightened  daily,  cuts  off 
the  entire  loop  left  outside  of  the  abdomen. 

The  special  features  of  this  operation  consist  in  the  production  of 
a  good  spur  and  the  removal  of  all  that  portion  of  the  sigmoid  which 
is  likely  to  prolapse  through  the  artificial  anus.  The  sacrifice  of  this 
intestine  seems  altogether  unnecessary.  The  pain  produced  by  the  slow 
cutting  of  the  clamp  is  very  trying  to  the  patient,  and,  finally,  the  opera- 
tion is  not  satisfactory  in  temporary  colostomy  on  account  of  the  amount 
of  gut  destroyed,  and  because  it  necessitates  either  enterotomy  or  in- 
testinal resection  to  close  it. 

Kelsey  fixes  the  sigmoid  in  the  wound  as  follows:  One  end  of  a 
silver  wire  is  prepared  with  a  metal  shield  held  on  by  a  perforated  shot, 
the  other  end,  threaded  to  a  strong,  sharp  needle,  is  passed  through  the 
entire  abdominal  wall  about  1  inch  to  the  right  of  the  abdominal  in- 
cision, then  through  the  mesentery,  and  back  through  the  abdominal 
wall  on  the  opposite  side  from  within  outward.  The  wire  is  drawn  taut, 
thus  bringing  the  edges  of  the  wound  in  close  apposition  with  the 
mesentery,  and  the  free  end  is  fastened  with  a  shield  and  shot  as  on 
the  opposite  side.  He  does  not  suture  the  peritonasum  and  skin  to- 
gether at  first,  but  brings  them  together  with  interrupted  silk  sutures, 


874 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


Fig. 


307. — CkOSS-SZCTIOX    AlTtlt    CoLUSToMV    BY 

Allixgham's  Method. 


each  passing  through  the  skin,  then  through  the  parietal  peritonaeum, 
and  then  through  the  peritoneal  and  muscular  coats  of  the  intestine. 

As  will  he  observed  from  the  cross-sections  (Figs.  30?,  308)  of 
the  preceding  operations,  the  posterior  wall  of  the  gut  is  below  the 
level  of  the  skin,  and  it  is  impossible  without  sacrificing  a  considerable 

portion  of  the  gut  to  pre- 
r  '      vent  the  escape  of  a  cer- 

tain amount  of  fsecal  ma- 
terial into  the  dependent 
segment. 

Bodine's  Method.  —  A 
very  efEectual  method  of 
producing  a  spur  is  that 
proposed  by  J.  A.  Bodine, 
of  XewYork.  It  consists  in 
drawing  a  loop  of  the  sig- 
moid well  out  of  the  wound 
and  uniting  its  afferent  and 
efferent  legs  to  the  extent 
of  about  2  inches  with  fine 
silk  sutures  placed  on 
either  side  of  the  mesen- 
tery about  ^  an  inch  apart. 
The  acutely  flexed  knuckle 
is  then  sutured  in  the  ab- 
dominal wound  so  that  it 
stands  well  above  the  level 
of  the  skin  (Fig.  309). 
After  the  gut  has  thor- 
oughly united  with  the  ab- 
dominal wound  and  thus 
sealed  off  the  peritoneal 
cavity,  this  protruding 
knuckle  is  amputated, 
leaving  a  double-barreled 
aperture  with  a  perpen- 
dicular division  which  ef- 
fectually prevents  the  passage  of  fa?cal  material  into  the  intestine 
below. 

The  originator  claims  that  an  artificial  anus  formed  in  this  manner 
can  be  safely  and  surely  closed  by  cutting  away  this  spur  through  the 
aid  of  Grant's  enterotome  (Fig.  310),  or  even  by  incising  it  with 
straight  scissors,  inasmuch  as  the  union  between  the  two  legs  pre- 


FlG. 


-Cp.OS?->ErTI.N    AKTER   COLOSTOMY   BY 

Kelsey's  Method. 


COLOSTOMY— COLOTOMY— ARTIFICIAL  ANUS 


875 


vents  any  danger  of  sncli  an  incision  penetrating  the  peritoneal  cavity. 
The  proposition  sounds  practical,  and  it  has  been  highly  indorsed  by 
many  of  our  best  surgeons.  The  author  has  never  employed  it,  however, 
because  it  is  believed  that  in  the  Maydl-Eeclus  method  there  is  a  simpler 
and  surer  means  to  accomplish  the  desired  ends  without  the  sacrifice  of 
any  portion  of  the  gut. 

Mathews  employs  long  harelip  pins  passed  through  the  abdominal 
walls  and  mesentery  to  support  the  gut  (Fig.  311).  Jeannel  has  advo- 
cated making  an  irregular  incision  in  the  skin,  passing  the  trans- 
verse part  of  the  flap  through  the  mesentery,  and  suturing  it  back  in 
its  normal  position,  thus 
using  it  as  a  means  of  sup- 
port for  the  gut.  These 
methods,  however,  possess 
no  advantages  over  those 
previously  described,  and 
the  difficulty  of  thor- 
oughly sterilizing  the  skin 
forms  an  insuperable  ob- 
jection to  the  method  of 
Jeannel. 

Tlie  Maydl-Reclus 
Method.— Majdl  (Cen- 
tralb.  f.  Chir.,  No.  34, 
1888)  suggested  support- 
ing the  loop  of  intestine 
drawn  out  of  the  inguinal 
wound  by  an  inflexible 
rod  made  of  vulcanized 
rubber  with  flanges  upon 
either  end.  The  tech- 
nique, as  he  first  proposed 
it,  consisted  in  drawing 
the  loop  out  through  the  wound,  making  a  small  incision  in  the  mesen- 
tery, care  being  exercised  to  avoid  the  blood-vessels,  then  passing  the  rod 
through  this  incision;  two  or  three  sutures  were  placed  so  as  to 
hold  the  intestine  together  below  the  rod,  and  then,  with  the  latter 
resting  upon  either  side  of  the  wound,  the  protruding  portion  of  the 
gut  was  sutured  to  the  skin  and  peritonaeum.  A  cross-section  after  this 
operation  shows  that  the  posterior  wall  of  the  gut  is  above  the  level  of 
the  abdominal  wall  (Fig.  312),  and  thus  forms  a  spur  beyond  which  the 
faeces  rarely  pass. 

With  some  modifications,  this  is  the  quickest,  simplest,  and  most 


Fig.  309. — Inguinal  Colostomy  (Bodine's  method). 


876 


THE   ANUS,   RECTUM,   AND   PELVIC   COLON 


satisfactory  method  of  col- 
ostomy. It  is  not  only  suit- 
able for  a  temporary  in- 
guinal anus,  but  an  artificial 
anus  made  by  this  method 
can  be  easily  converted  into 
the  permanent  type  if  it  is 
found  inadvisable  to  close 
the  aperture. 

Maydl  and  Keclus  opened 
the  gilt  by  transverse  inci- 
sion in  a  line  with  the  sup- 
porting rod  and  extending 
two-thirds  around  the  cir- 
cumference of  the  gut.  This 
incision  was  made  with  a 
Paquelin  cautery  immedi- 
ately after  the  gut  was  fixed 
in  position  or,  if  the  case 
was  not  urgent,  two  or  three 
days  later.  After  two  or 
three  weeks  the  remainder 
of  the  circumference  of  the 
gut  was  cut  through  upon  the  rod  in  a  like  manner,  and  the  protruding 
ends  were  sutured  to  the  skin  around  the  wound.     This  treatment  of 


Fig.  310. — Enterotomy  aftek  Colostomy  by 
Bodine's  Method. 


i'la.  311. — Inuuinal  CoLusTuiiv  (Muthevvs's  method;. 


COLOSTOMY— COLOTOMY— ARTIFICIAL   ANUS 


877 


Fig.  312. — Cross-section  after  Colostomy  by 
Maydl-Keclus  Method. 


the  gut  necessitates  a  resection  of  the  bowel  in  case  it  is  deemed  wise 
to  close  the  artificial  anus  at  a  later  date,  and  therefore  it  is  to  be 
rejected. 

The  Author's  Technique 
for  Temporary  Inguinal 
Colostomy.  —  An  incision 
through  the  skin  and  su- 
perficial fascia  is  made  in 
a  line  with  the  fibers  of 
the  external  oblique  mus- 
cle, beginning  at  a  point 
1  inch  above  and  1^  inch 
inside  of  the  anterior  su- 
perior spine  of  the  ilium. 
It  should  be  at  least  3 
inches  in  length.  The 
fibers  of  the  external  and 
internal  oblique  are  sepa- 
rated with  a  dull  instru- 
ment and  drawn  apart  with  broad  retractors.  The  fascia  transversalis 
is  then  divided  by  incision  in  the  line  of  Poupart's  ligament.  At  this 
point  all  bleeding  vessels  are  ligatured  and  the  wound  thoroughly  dried 

with  sterilized  gauze. 
The  peritonaeum  is 
then  opened  by  a 
small  nick,  the  finger 
being  introduced 
through  this  as  a 
guide,  and  the  mem- 
brane incised  the 
whole  length  of  the 
wound  in  the  trans- 
versalis fascia;  its 
edges  are  caught  with 
haemostatic  forceps 
and  drawn  up  into  the 
wound.  The  hand  of 
the  operator  is  then 
introduced  and  a  thor- 
ough exploration  of 
the  abdominal  and 
pelvic  cavities  is  made.  After  this  has  been  done,  if  it  is  found 
advisable  to  proceed  with  the  temporary  artificial  anus,  the  sigmoid 


Fig.  313. — Temporary  Ixguinal  Colostomy. 
Eod  being  passed  through  mesentery. 


8TS 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


is   cau<zlit,   drafraecl   out   of   tlio   wound,   and    the   proper   point   to   be 


utilized  is  determined  upon. 


Fig.  314. — Tempokary  Inguinal  Colostomy 
Gut  supported  on  rod  and  sutures  in  position. 


A  small  incision  is  then  made  through 
the  mesentery,  care 
being  taken  to  avoid 
the  blood-vessels,  and 
a  glass  rod  about  ^ 
of  an  inch  in  diameter 
and  4:  inches  in  length 
is  passed  through  this, 
its  ends  resting  upon 
either  side  of  the 
wound  (Fig.  313). 
The  lower  angle  of 
the  wound  is  then 
closed  by  silkworm- 
gut  sutures  passed 
through  all  its  coats 
to  such  an  extent  that 
it  compresses  the  in- 
ferior leg  of  the  in- 
testinal loop  against  the  glass  rod.  Fine  chromicized  catgut  sutures 
are  then  passed  at  the  two  angles  of  the  wound  through  the  skin  and 
peritoneum,  then  through  the  muscular  wall  of  the  gut,  and  back 
through  the  peritonaeum 
and  skin  upon  the  opposite 
side  (Fig.  314).  Small  pads 
of  iodoform  gauze  are  in- 
troduced \inder  the  pro- 
truding ends  of  the  glass 
rod  and  along  the  edges  of 
the  wound  close  to  the  in- 
testine after  the  latter  has 
been  smeared  with  steril- 
ized vaseline.  The  whole 
is  dressed  with  protective 
tissue  covered  by  a  thick 
pad  of  gauze  or  cotton, 
which  is  held  in  position 
by  adhesive  straps  and  a 
firm  abdominal  bandage. 
The  gut  is  never  opened 
at  this  time.  If  there  is 
great  distention  by  gas,  a 


6^»./A^^:-... 

1 

■1 

1 

\  ^<^- 

f 

1 

1 

Fig.  315. — Ixcisiox  fok  opexixg  the  Gut  in 
Temporary  Ixguixal  Colostomy. 


COLOSTOMY— COLOTOMY— ARTIFICIAL  AXUS 


879 


trocar  is  inserted  to  allow  its  escape.  After  this  has  taken  place,  the 
opening  made  by  the  trocar  is  closed  by  tAvo  Lembert  sutures  and 
sealed  with  iodoformized  collodion.  The  patient  is  placed  in  bed  with 
his  hips  well  elevated,  and  is  given  sufficient  morphine  hypo- 
dermically  to  control  vomiting  and  intestinal  peristalsis  for 
the  succeeding  ten  or  twelve  hours.  The  gut  ma}'  be  opened 
with  perfect  safety  at  any  time  after  the  first  six  hours,  al- 
though it  is  better  to  wait  two  or  three  days  in  cases  which 
will  admit  of  such  delay.     This  opening  should  be  made  by 


Fig.  316. — DrprTTREx's  E>'TEROToirE. 


an  incision  through  the  longitudinal  muscular  band  opposite  the  mesen- 
tery, extending  from  the  superior  angle  of  the  wound  to  -J  an  inch  below 
the  supporting  rod.    A  transverse  incision  is  then  made  at  the  lower  end 


Fig.  317. — ISiELATON'a  Intestesal  Cla3ip. 


of  this  wound  involving  two-thirds  of  the  circumference  of  the  gut  (Fig. 
315).  By  this  means  the  triangular  flaps  in  the  upper  segment  roll  back- 
ward and  curl  up  like  dried  leaves.    The  straight  flap  in  the  lower  seg- 


FiG.  318. — CoLLiNs's  Lo^•&  Cla^ip  Forceps. 


ments  falls  downward  and  inward,  practically  closing  the  lower  aperture. 
The  fgecal  discharges  are  thus  carried  outside  of  the  abdorj^inal  cavity, 
and  there  is  scarcely  any  possibility  of  their  escaping  into  the  lower 


880 


THP]  ANUS,    RECTUM,   AND   PELVIC   CObON 


se<nneiit.     In  addition  to  this,  no  portion  of  the  intestinal  wall  is  sacri- 
ficed, and  when  it  becomes  advisable  the  artificial  anus  can  be  closed  by 


Fig.  319a.— Murphy  Button 

CLOSED. 


Fig.  319. — MuKi'iiy  Button  open. 


simply  suturing  the  edges  of  the  T-shaped  wound  together  without 
opening  the  peritoneal  cavity.  At  the  same  time  the  lower  segment 
may  be  opened  by  simply  lifting  up  the  transverse  flap,  thus  furnishing 

an  opportunity  for  irriga- 
tion and  treatment  of  the 

parts  below  so  long  as  is 

necessary. 

In  this  operation  the 

author    adheres    to    the 

principle    laid    down    in 

the  foregoing  pages  with 

regard  to  the  portion  of 

the  sigmoid  in  which  the 

artificial  anus  ought  to  be 

made.     If  the  disease  is 

to  be  treated  by  resection 

of  a  portion  of  the  gut 

below,  the  artificial  anus 

is  made  high  up  in  the 

sigmoid  in  order  that  as 

much  as  possible  of  this 

organ  may  be  left  below 
to  be  utilized  in  the  reestablishment  of  the  natural  intestinal  canal. 
The  longer  the  loop  thus  left  below  the  artificial  anus,  the  easier  will 


Fig.  320.— Senn's  Decal- 
cified Bone-plate. 

«,  fixation  sutures  ;  6,  ap- 
proximation sutures ; 
c,  opening.s  in  plate 
and  anchor  thread. 


Fig.  321. — Laplace's  Forceps 
FOR  Intestinal  Resection. 


COLOSTOMY— COLOTOMY— ARTIFICIAL   AXUS 


881 


be  the  subsequent  operation  of  extirpation  or  resection.     The  glass  rod 
is  retained  in  position  for  t-^-o  weeks,  or  even  longer.     It  occasions  the 


Fig.  322.— O'Hara's  CLAiips. 


patient  no  inconvenience,  and  it  is  prevented  from  slipping  out  of  place 
by  a  narrow  strip  of  adhesive  plaster  around  each  end  and  fastened 
to  the  abdominal  wall  above  the  wound. 


Fig.  323. — Isolation  of  Diseased  Portion 
or  Gut  by  0'Haba"s  Method. 


Fig.  324. — Diseased  Portion  excised  and 
Edges  of  Peeitonj:um  brought  together 
(O'Hara). 


If  unexpectedly  it  becomes  necessary  to  convert  this  temporary  arti- 
ficial anus  into  a  permanent  one,  this  can  be  accomplished  by  cutting 
through  the  posterior  wall  of  the  gut,  which  is  supported  upon  the 
56 


882 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


rod,  and  trimming  off  the  protruding  edges  to  within  about  1  centi- 
meter (I  of  an  inch)  of  the  skin.  The  opening  of  the  intestine  requires 
no  anaesthesia  whatever.     Unless  the  cutting  involves  the  mesentery. 


Fig.  325. — Sftures  introdtjced  over 
Forceps  (O'Hara). 


Fig.  326. — Sutures  tied  and  Forceps  ready 
TO  BE  WITHDRAWN  (O'Hara). 


there  is  no  pain  connected  with  this  part  of  the  operation,  and  the 
haemorrhage  is  always  so  slight  that  it  need  not  give  any  anxiety.  When 
the  mesentery  is  incised,  however,  local  or  light  general  anesthesia 

ought  to  be  employed,  as  the 
sensitive  nerves  of  the  gut 
seem  to  be  located  in  this 
portion,  and  any  cutting  here 
occasions  considerable  pain. 
There  is  also  likely  to  be  con- 
siderable bleeding  from  this 
incision,  which  should  be  con- 
trolled by  twisting  or  ligating 
the  arteries. 

Closure    of    a     Temporary 

Artificial  Anus. — The  method 

of    closing    an    artificial    anus 

will    depend    altogether   upon 

the   manner   in   which   it   has 

been  made.    In  operations  such 

as  Allingham's  and  Bodine's  one  may  follow  one  of  two  plans:  First, 

the  spur  ma}^  be  cut  away  with  an  enterotome  (Figs.   316,  317).     A 

straight  hysterectomy  or  long  clamp  forceps  (Fig.  318)  serves  very  well 


Fig.  327. — Git  seized  for  Lateral  Entero- 

ANASTOMOSIS   BY    O'HaRA's   MeTHOD. 


COLOSTOMY— COLOTOMY— ARTIFICIAL   ANUS 


883 


for  this  purpose.  The  blades  of  the  instrument  are  introduced  one 
into  the  upj^er  and  the  other  into  the  lower  aperture  of  the  gut,  and 
they  are  gradually  tightened  day  by  day  until  they  cut  their  way  through 
by  necrosis  of  the  tissues.  This  process  is  exceedingly  painful  to  the 
patient,  and  it  requires  two  to  sis  days  to  accomplish  it.  After  this 
the  fgecal  current  will  generally  pass  downward  through  the  rectum, 
and  the  artificial  anus  may  heal  spontaneously.  If  this  does  not  occur, 
the  edges  of  the  gut  around  the  abdominal  opening  may  be  dissected 
up  from  the  skin  and  closed  by  Czerny-Lembert  sutures,  the  skin 
being  brought  together  above  the  freshened  surfaces.  It  is  perfectly 
evident  that  this  method  will  result  in  a  very  abnormal  condition 
of  the  intestine,  neverthe- 
less quite  satisfactory  re- 
sults may  be  obtained 
through  it. 

The  second  method  con- 
sists in  dissecting  the  ends 
of  the  gut  loose  from  their 
attachments  to  the  abdom- 
inal wall,  freshening  their 
edges,  and  uniting  them  by 
end-to-end  or  lateral  anas- 
tomosis. This  may  be  done 
by  the  aid  of  the  Murphy 
button  (Fig.  319),  Senn's 
bone-plates  (Fig.  320),  or 
by  suturiug  with  or  without 
the  use  of  the  Laplace  or 
O'Hara  clamps  (Figs.  331, 
332).  The  latter  instru- 
ment is  a  most  ingenious 
and  practical  one.     It  not 

only  facilitates  the  suturing,  but  it  at  the  same  time  controls  hasmor- 
rhage  and  prevents  the  escape  of  iatestinal  contents  into  the  wound. 
The  method  of  employing  it  has  been  graphically  described  by  the 
inventor  (Amer.  Jour,  of  Obstetrics,  vol.  xlii,  p.  83),  and  is  easily 
understood  from  the  accompanying  illustrations  (Figs.  333,  324,  325, 
336,  327,  328).  This  operation  involves  opening  the  peritoneal  cav- 
ity, and  is,  in  fact,  more  dangerous  than  an  ordinary  resection  of 
the  gut,  because  it  is  difficult,  without  considerable  sacrifice  of  the 
organ,  to  obtain  portions  which  are  completely  covered  with  peri- 
tongeum.  The  various  methods  of  resecting  and  reuniting  the  ends 
of  the  intestine  are  described  in  works  on  general  surgery.     An  excel- 


FiG.  328. — Lateral  ExTEEO-AXASTOiiosis  (second  step 
in  O'Hara's  method^. 


884  THE  ANUS,  RECTUM,  AND   PELVIC  COLON 

lent  resume  of  tlic  lcclnii(iuc  will  hi'  found  in  JJryant's  Operative  Sur- 
gery, vol.  ii,  to  which  we  are  indebted  for  numerous  illustrations. 

After  operations  by  the  Cripps,  Kelsey,  or  other  methods,  in  which 
only  a  part  of  the  intestinal  circumference  has  been  destroyed,  the 
artificial  anus  may  sometimes  be  successfully  closed  by  a  plastic  opera- 
tion, after  the  manner  of  Szymanowski's  procedure  for  closure  of  ure- 
thro-perineal  fistula.  A  curved  incision,  ABC  (Fig.  330),  is  made 
through  the  skin  internal  to  the  artificial  anus.  This  is  dissected  up 
for  about  1  inch  from  the  opening  to  the  dotted  line  ADC.  A  second 
curved  incision,  AEC,  is  made  on  the  opposite  side,  about  1|  inch  from 

the  artificial  anus.  The 
superficial  layer  of  the  skin 
is  dissected  off  from  this 
flap  with  the  exception  of 
a  small  portion  immedi- 
ately surrounding  the  arti- 
ficial anus  sufficiently  large 
to  cover  the  latter  aper- 
ture. The  fiap  is  then 
raised  over  the  entire  area, 
AFCE,  leaving  it  well  at- 
tached around  the  artificial 
anus.  It  is  then  folded 
over  on  this  hinge-like  at- 
tachment and  sutured  to 
the  freshened  surface  from 
which  the  flap  ABCD  has 
been  raised.  To  prevent 
their  cutting  into  the 
skin,  these  sutures  should 

Fig.     329.-LATEKAL    ENTERO-ANA9TOM09I9     COMPLETE,,  ^^^      ^-^^^      ^^^^      pledgCtS      of 

(0  Haras  method).  ^         ^ 

gauze.  The  flap  ABC  is 
then  dragged  across  and  sutured  to  the  margins  of  the  incision  AEC 
(Fig.  331).  In  this  manner  the  artificial  anus  is  closed  by  a  double 
layer  of  skin  without  opening  the  peritoneal  cavity.  Parker  Syms  and 
others  have  succeeded  in  closing  artificial  ani  after  this  manner. 

When  the  colostomy  has  been  done  after  the  author's  method,  it  may 
be  closed  as  follow^s:  The  little  triangular  flaps  in  the  upper  segment, 
which  curl  up  and  become  adherent  in  their  peritoneal  layers,  are  un- 
rolled by  carefully  breaking  up  these  adhesions  with  dull  instruments 
or  with  the  finger  nail.  Their  edges  are  then  freshened,  together  with 
that  of  the  lower  transverse  flap.  The  T-shaped  wound  in  the  gut  is 
then  brought  together  by  silk  sutures  passed  through  the  mucous  mem- 


COLOSTOMY— COLOTOMY— ARTIFICIAL   ANUS 


Fig.  330. — Closure  of  Akth'icial  Ajtus  by  Plas- 
tic Method. 


brane,  after  the  manner  of  Czemy,  and  a  row  of  Lembert  sutures  out- 
side of  these.  After  this  has  been  accomplished,  the  gut  is  dissected 
loose  from  its  attachment  to  the  abdominal  wall  down  to  the  peritoneal 
layer.  This  layer  is  carefully  stripped  from  the  abdominal  wall  to  the 
extent  of  about  1  inch  all  around  the  artificial  anus.  This  loosening 
provides  a  loop  of  peritonaeum  which  allows  the  closed  gut  to  drop  down 
below  the  level  of  the  abdominal  wall  (Fig.  332).  The  opening  in 
the  latter,  already  freshened 
by  dissecting  loose  the  intes- 
tine, is  then  brought  together 
by  silkworm-gut  sutures  passed 
through  all  its  layers.  By 
this  method  the  gut  is  effec- 
tually closed  with  very  slight, 
if  any,  diminution  in  its  cali- 
ber, without  opening  the  peri- 
toneal cavity,  and  the  abdom- 
inal wall  is  restored  in  all  its 
thickness,  which  is  a  matter 
of  considerable  importance  in 
the  prevention  of  hernia. 

Permanent  Colostomy.  — 
The  chief  requisites  of  a  per- 
manent artificial  anus  consist 
in  an  effectual  outlet  for  the 
faecal  discharges,  convenience 
in  its  management  by  the  pa- 
tient, the  absence  of  prolapse, 
and  the  greatest  possible  fscal 
control.  It  is  generally  con- 
ceded that  an  artificial  anus 
in  the  inguinal  region  can  be 
better  attended  to  by  the  pa- 
tient himself  than  in  the  lum- 
bar, gluteal,  or  sacral  posi- 
tions. It  will  also  be  admitted 
that  prolapse  is  no  more  like- 
ly to  occur  in  this  position  than  elsewhere.  It  may  therefore  be  as- 
sumed that  the  inguinal  site,  when  practicable,  is  the  most  satisfactory 
one.  An  effectual  outlet  for  the  ffecal  material  can  be  easily  obtained 
in  any  one  of  the  positions  mentioned.  Control  of  fa?cal  discharges  is, 
therefore,  the  most  important  subject  in  connection  with  permanent 
colostomv.     The  constant  escape  of  gas  and  faces  from  artificial  ani 


Fig.  331. 


-Closure  of  Artificial  Axus  by  Plas- 
tic Method  Completed. 


886 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


Fig.  332. — <  !;■  ■-— -k.  tion  after  E.xtr a- peritoneal. 
Closure  of  Artificial  Anus. 


has  brought  tlie  operation  into  disrepute  with  both  patients  and  sur- 
geons. The  former  are  usually  well  satisfied  for  a  time  by  the  relief 
from  pain  and  improvement  in  their  general  condition  due  to  the  regu- 
lar action  of  their  bowels 
through  tlie  newly  formed 
exit;  but  when  they  learn 
that  the  opening  is  to  be 
permanent;  that  they  have 
no  control  over  their  pas- 
sages; that  they  are  de- 
barred from  society,  busi- 
ness, and  travel,  and  in 
addition  to  all  this  that 
the  operation  has  not  been 
curative,  a  dissatisfaction 
arises  which  ends  in  men- 
tal depression  and  some- 
times in  deep  melancholy. 
The  mental  condition  of  such  patients  is  pitiable  indeed.  Therefore, 
when  it  is  known  beforehand  that  an  artificial  anus  is  to  be  a  perma- 
nent affair,  it  should  certainly  be  fashioned  so  as  to  give  the  patient 
the  greatest  possible  control  of  the  f?ecal  discharges. 

The  greatest  improvements  in  permanent  colostomy  have  been  along 
this  line.  Numerous  ingenious  mechanical  appliances  have  been  devised 
in  the  form  of  bags  to  catch  the  escaping  faeces,  and  pads  or  plugs  to  ob- 
struct the  fgecal  exit.  One  of  the  best  of  these  is  the  double  inflatable 
bulb  of  Weir,  a  modification  of  Jacobson's  intestinal  plug.  The  two 
bulbs  are  connected  by  a  hollow,  hard-rubber  tube  for  ease  of  introduc- 
tion, and  furnished  with  a  stop-cock  to  prevent  the  escape  of  air. 
The  lower  bulb  is  passed  into  the  proximal  opening  of  the  artificial 
anus  and  inflated.  The  upper  bulb,  covered  with  a  perforated,  hard- 
rubber  disk,  rests  upon  the  external  surface  and  holds  the  lower  against 
the  inner  surface  of  the  abdominal  wall,  thus  occluding  the  opening. 
The  whole  is  held  in  position  by  adhesive  straps  passed  across  the  rubber 
disk  and  attached  to  the  abdominal  wall.  Various  modifications  of  these 
plugs  have  been  devised,  but  apparatuses  of  this  type,  while  they  control 
the  faeces  and  are  satisfactory  for  a  time,  usually  produce  so  much  local 
and  reflex  irritation  that  it  is  impossible  for  patients  to  employ  them 
for  any  great  length  of  time. 

Many  surgical  devices  have  also  been  employed  to  establish  fa?cal 
control  in  artificial  ani.  Among  these  may  be  mentioned  twisting  of 
the  gut  after  the  manner  of  Gersuny,  rotating  the  intestinal  loop  in  the 
abdominal  wound  so  that  the  proximal  opening  will  be  below  the  distal, 


COLOSTOMY— COLOTOMY— ARTIFICIAL   ANUS 


887 


and  suturing  the  abdominal  wound  so  closely  as  to  constrict  the  external 
aperture  in  the  gut.  Xone  of  these,  however,  has  jDroved  successful. 
Many  efforts  have  been  made  to  establish  an  involuntary  sphincter  from 
the  circular  fibers  of  the  gut.  In  one  case  the  author  apparently  accom- 
plished this  by  making  tucks  in  the  gut  just  above  its  point  of  exit 
from  the  abdominal  wound  by  introducing  several  fine  silk  sutures 
longitudinally  through  the  muscular  la3'ers  for  about  1  inch,  the  ends 
of  which,  being  tied  together,  produced  an  aggregation  of  circular  fibers 
at  this  point.  The  patient  lived  ten  years  after  the  operation,  and  always 
had  comparatively  good  control.  Subsequent  trials  of  this  method,  how- 
ever, were  not  so  successful.  One  of  the  most  ingenious  of  these  at- 
tempts is  that  of  Bernays,  and  was  termed  by  him  "  sphincteropcesis." 
After  fixing  the  gut  and  allowing  it  to  adhere  in  position,  he  cut  it 
across;  he  then  dissected  the  mucous  membrane  and  submucosa  loose 
from  the  proximal  opening  in  the  gut  for  the  distance  of  1  inch,  thus 
exposing  the  circular  muscular  fibers.  The  latter  were  then  caught  by 
catgut  sutures  running  longitudinally  and  matted  together.  The  mu- 
cous membrane  was  then  trimmed  off  to  the  proper  lengih  and  sutured 
back  in  its  original  position.  The  results  of  this  operation,  however, 
were  not  satisfactory. 

xVnother  attempt  in  this  line  consisted  in  tying  a  strong  silk  ligature 
around  the  intestine,  just  above  its  exit,  sufficiently  tight  to  narrow  the 
caliber  to  about  the  size  of  the  index  finger.  The  ligature  was  buried 
by  suturing  the  perito- 
neal coats  of  the  gut 
over  it  (Fig.  333).  This 
ojaeration  has  nothing 
to  commend  it.  Howse 
(Holmes's  System  of 
Surger}^  vol.  i,  p.  801) 
first  suggested  bringing 
the  loop  of  sigmoid  out 
through  the  fibers  of 
the  rectus  abdominis, 
thus  hoping  to  obtain 
some  sphincteric  con- 
trol from  the  contrac- 
tions of  this  muscle. 
Yon  Hacker  (Beitrage 

zur  klin.  Chirur.,  1899,  S.  628)  advised  splitting  the  rectus  muscle 
both  vertically  and  laterally,  and  then  dragging  the  loop  of  sigmoid 
through  this  split;  this  operation  is  very  difficult,  and  the  amount 
of  control  obtained  is  not  at  all  satisfactory.     In  fact,  none  of  these 


Fig.   3-33. — Ligati-re   thro-wx   ARO^^^)   Proximal   Loop   of 
Gut  IK  CoLOSTOiiT  ix  order  to  secure  Fj:cal  Coxtkol. 


888 


THE  ANUS,  RECTUM,  AND  PELVIC  COLON 


methods  was  any  improvement  upon  the  Maydl-Eeclus  procedure  car- 
ried out  by  separating  instead  of  cutting  the  muscular  layers  of  the 
abdominal  wall. 

The  first  real  advance  toward  the  establishment  of  the  modern  per- 
manent   inguinal   anus    was    that    of    Witzel    (Centralblatt    fiir    Chir., 

1894,  Xo.  40),  who, 
instead  of  bringing  the 
loop  of  intestine  out 
through  the  first  ab- 
dominal wound,  made 
a  canal  for  it  by  sepa- 
rating the  external  and 
internal  oblique  mus- 
cles over  the  brim  of 
the  pelvis,  and  sutured 
it  to  the  opening  in  the 
skin  1  inch  below  (Fig. 
334).  Bailey  modified 
this  operation  of  Wit- 
zel by  carrying  the  in- 
testine down  between 
the  skin  and  the  exter- 
nal oblique  muscle,  and 
bringing  it  out  through 
an  opening  in  the  skin 
just  above  Poupart's 
ligament,  2  inches  below  the  abdominal  incision  (Fig.  335).  Braun  (Bry- 
ant's Operative  Surger}^,  vol.  ii,  p.  996)  proposed  closing  the  lower  seg- 
ment of  the  gut  after  the  manner  of  Schinzinger,  dropping  it  back  in  the 
abdomen,  and  then  carrying  the  upper  segment  underneath  the  skin 
to  an  opening  on  the  anterior  surface  of  the  thigh  (Fig.  336).  Witzel, 
and  Lenkinheld  and  Borchardt,  who  have  applied  his  ftiethod,  state 
that  their  patients  all  possessed  excellent  sphincteric  control  of  both 
gas  and  faeces  without  the  aid  of  any  bandage  or  compress  whatever. 
The  fact,  however,  that  it  is  often  impossible  to  obtain  a  loop  of  sig- 
moid sufficiently  long  to  be  brought  out  over  the  brim  of  the  pelvis, 
renders  this  operation  a  very  uncertain  procedure.  In  Bailey's  method, 
as  well  as  that  of  Paul,  a  truss  or  compress  placed  upon  the  intestine 
as  it  passes  from  its  exit  from  the  abdominal  cavity  underneath  the 
skin  will  effectually  control  both  fgecal  and  gaseous  passages,  but  with- 
out such  a  compress  this  control  is  not  so  perfect  as  that  claimed  for 
the  Witzel  method. 

Weir  (Med.  Record,  1900,  p.  666)  has  combined  the  Schinzinger  and 


Fig.  334. — Witzel's  Method  of  Colostomy. 

The  loop  of  intestine  lield  by  ligature  is  dragged  through 
canal  made  between  external  and  internal  oblique  muscles 
and  brought  out  through  opening  in  skin  indicated  by  line 
belov\-  crest  of  ilium. 


COLOSTOMY— COLOTOMY— ARTIFICIAL  ANUS 


889 


J' 


Witzel  methods  as  follows:  The  ordinary  incision  for  inguinal  colotomy 
is  made  through  the  abdominal  wall,  and  the  loop  of  sigmoid  in  which 
the  artificial  anus  is  to  be  made  is  dragged  out  of  the  abdomen.  It  ia 
then  cut  in  two,  the  lower  end  being  invaginated,  closed  with  Lembert 
sutures,  and  dropped  back  into  the  abdominal  cavity.  A  canal  is  then 
formed  by  separating  the  external  from  the  internal  oblique  muscles 
out  to  the  crest  of  the  ilium,  at  which  point  the  fascia  is  divided  and 
the  canal  continued  underneath  the  skin  to  a  point  about  2  inches  out- 
side of  and  below  the  crest.  The  upper  end  of  the  gut  having  been 
disinfected  and  tied  with  a  ligature,  the  ends  of  which  are  left  long, 
is  then  dragged  through  this  canal  and  attached  to  the  skin  around  the 
opening  in  the  gluteal  region  (Fig.  337).  The  abdominal  opening  is 
then  closed,  the  gut  being  sutured  to  the  parietal  peritonaeum  at  the 
point  of  its  exit  from 
the  peritoneal  cavity. 
Great  care  must  be  ex- 
ercised in  incising  the 
mesocolon  to  loosen  the 
intestinal  loop  lest  its 
circulation  be  inter- 
fered with  and  gan- 
grene result,  as  hap- 
pened in  one  case  of 
Weir's.  Theoretically 
there  are  two  objec- 
tions to  this  opera- 
tion: First,  the  situa- 
tion of  the  artificial 
anus  would  appear  to 
be  very  inconvenient; 
second,  the  closure  and 
dropping  back  of  the 
distal  end  of  the  gut 
destroys  all  opportu- 
nity of  disinfection  and 
treatment  of  the  lower 
segment  through  the 
artificial  opening.    The 

latter  objection  may  be  overcome  by  suturing  the  lower  end  in  the 
inguinal  wound  and  opening  it  at  a  later  period  after  it  has  thoroughly 
adhered.  Witzel,  Borchardt,  and  Weir  report  that  their  patients  suf- 
fered no  inconvenience  from  the  situation  of  the  anus,  and  we  may 
therefore  assume  that  the  first  objection  is  without  any  particular  force. 


Fig.  S35. — Bailey's  Method  of  Peritanent  Colostomt. 


890 


THE  ANUS,  RECTUM,   AND  PELVIC  COLON 


Fig.  336. — BRAr>'s  Method  of  Per- 
MAXEXT  Colostomy.     (Bryant.) 


On  account  of  its  ease  in  execution  and  most  satisfactory  results  ob- 
tained from  it,  the  author  employs  the  following  modification  of  Bailey't^ 
method  in  permanent  colostomy. 

Author's  Method. — The  operation  is  begun  by  the  ordinary  incision 
for  inguinal  colotomy.     The  fibers  of  the  external  and  internal  oblique 

muscles  are  separated  by  a  blunt  in- 
strument instead  of  being  cut.  The 
transversalis  fascia  and  peritonaeum 
are  incised  in  a  line  parallel  to  Pou- 
part's  ligament.  After  abdominal  ex- 
ploration has  been  carried  out  with  the 
hand  and  a  permanent  inguinal  colos- 
tomy has  been  finally  determined  upon, 
a  loop  of  sigmoid  sufficiently  long  to 
be  drawn  at  least  2  inches  outside  of 
the  abdominal  cavity  is  selected,  and  a 
tape  or  loop  of  large  silk  is  passed 
around  it  through  a  small  slit  in  the 
mesentery,  the  ends  being  left  long  and 
held  by  an  artery  forceps.  The  lower 
fibers  of  the  external  oblique  are  then  pulled  downward,  and  the  internal 
oblique  is  split  laterally  to  the  distance  of  about  2  centimeters  (f  inch). 
A  canal  is  then  made  between  the  skin  and  the  external  oblique  down- 
ward to  the  extent  of 

about   2   inches,   open-  'M^  j 

ing   through   an   inci-  }s 

sion  in  the   skin  just  ^ 

above  Poupart's  liga- 
ment (Fig.  338).  This 
canal  and  incision 
should  be  large  enough 
to  admit  of  the  loop  of 
sigmoid  being  drawn 
through  them  without 
much  compression. 
With  the  aid  of  the 
dressing  forceps  the 
knuckle  of  gut  is  then 
dragged  through  the 
lateral  slit  in  the  in- 
ternal oblique  and 
downward  through  the  canal  outside  of  the  external  oblique  muscle 
until  it  emerges  at  the  inferior  opening  in  the   skin.     It  is  held 


Fig.  337.— Weii 


Method  or  Permaxext  Colostomy, 
(Bryant.) 


COLOSTOMY— COLOTOMY— ARTIFICIAL  ANUS 


891 


in  this  position  either  by  the  passage  of  a  glass  rod  through  tlie 
opening  in  the  mesentery,  or  by  suturing  it  to  the  edges  of  the 
skin  wound.  The  abdominal  wound  is  then  closed  by  chromicized  cat- 
gut sutures  in  the  muscular  layers  and  a  subcutaneous  silk  suture  in 
the  skin;  it  is  then  sealed  by  iodoformized  collodion  and  dressed  with 
sterilized  gauze,  over  which  a  layer  of  rubber  protective  tissue  is  placed 
and  sealed  to  the  skin  with  chloroform.  This  latter  precaution  is  taken 
to  avoid  infection  of  the  primary  wound  through  the  escape  of  fasces 
when  the  gut  is  opened. 
If  necessary,  the  loop 
of  intestine  may  be 
opened  immediately, 
but  ordinarily  it  is  bet- 
ter to  wait  twenty-four 
to  forty-eight  hours  be- 
fore doing  so.  This  is 
accomplished  by  a  sim- 
ple slit  in  the  line  of 
the  longitudinal  fibers 
of  the  gut.  After  ten 
days  or  more,  the  pro- 
truding portions  of  the 
gut  should  be  trimmed 
down  flush  with  the 
skin  and  the  artificial 
anus  will  present  itself 
as  a  double-barreled 
aperture,  one  opening 
of  which  connects  with 
the  proximal  and  the 
other  with  the  distal 
end  of  the  sigmoid 
(Fig.  339).  The  gut 
is  brought  outside  of 
the     external     oblique 

muscle  in  order  that  it  will  rest  upon  a  resisting  plane,  and  a  truss 
or  compress  can  be  placed  upon  it,  thus  absolutely  occluding  its  caliber. 
Being  passed  through  the  slit  in  the  internal  oblique,  it  is  surrounded 
by  muscular  fibers,  and  thus  obtains  a  certain  amount  of  voluntary 
control.  In  the  majority  of  cases  no  compressing  apparatus  is  neces- 
sary, as  the  patient  usually  possesses  almost  complete  continence  with- 
out it.  When  it  is  necessary,  an  ordinary  single  spring  hernial  truss 
with  an  elongated  pad  placed  somewhat  outside  of  the  usual  position 


Fig.  338. — Permanent  Colostomy  (autlior's  method). 

The  gut  being  dragged  through  the  split  internal  oblique 
and  then  through  the  subcutaneous  canal. 


892 


THE   ANUS,   RECTUM,   AND   PELVIC  COLON 


serves  exery  purpose.  The  author  has  practised  this  method  in  T  cases, 
and  in  only  2  of  them  has  a  truss  been  necessary.  With  the  latter 
in  position,  the  continence  was  so  perfect  that  it  was  necessary  for 

the  patient  to  raise 
the  truss  in  order  to 
allow  the  escape  of 
intestinal  gases.  Xot 
only  is  the  conti- 
nence obtained  by 
this  method  exceed- 
ingly satisfactory,  but 
the  site  of  the  anus  is 
very  convenient  for 
the  patient.  He  can 
sit  upon  an  ordinary 
toilet-seat  with  a  pus 
basin  held  underneath 
the  artificial  anus  and 
relieve  his  bowels  with 
as  little  inconvenience 
as  if  the  anus  were  in 
the  normal  position. 
The  parts  can  be  eas- 
ily cleaned,  and  in 
the  cases  thus  far  ob- 
served there  has  never 
been  the  slightest 
tendency  toward  pro- 
lapse. The  inferior 
segment  of  the  sigmoid  can  also  be  washed  out  and  irrigated  through 
this  type  of  permanent  artificial  anus,  thus  obviating  the  danger  of  col- 
lections of  pus  and  putrefying  substances  in  this  portion  ot  the  gut. 

Colostomy  on  the  Right  Side. — Inguinal  colotomy  upon  the  right  side 
differs  from  that  upon  the  left  on  account  of  the  anatomical  variations 
in  the  parts.  The  ascending  colon  is  not  situated  as  low  down  in  the 
pelvis  as  the  descending  colon;  it  is  not  continuous  with  a  gut  of  like 
caliber,  but  united  at  an  angle  with  the  ileum;  it  ends  in  a  blind  pouch 
to  which  is  attached  the  appendix  vermiformis,  which  may  prove  a  seri- 
ous complication  in  colotomy  on  the  right  side;  and  finally,  the  mesen- 
tery of  the  ascending  colon  is  usually  so  short  that  it  is  very  diflFieult 
to  bring  a  loop  outside  of  the  abdominal  wall  and  thus  form  an  efficient 
spur  for  the  prevention  of  fasces  passing  into  the  portion  of  the  gut 
above  the  artificial  anus. 


Fig.  339. — Permaxext  Colostomy  by  Acthor's  Method 
Completed. 


COLOSTOMY— COLOTOMY— ARTIFICIAL  ANUS  893 

Another  point  of  importance  with  regard  to  colotomy  upon  the  right 
side  is  tlie  fact  that  the  faeces  are  ahnost  always  fluid  in  this  portion  of 
the  intestine,  and  under  such  circumstances  it  is  almost  impossible  to 
form  a  permanent  artificial  anus  which  will  possess  any  degree  of  faecal 
continence  on  this  side.  Happily  it  is  very  rarely  necessar}^  to  make  a 
permanent  artificial  anus  at  this  site.  Temporary  colostomy  in  this  posi- 
tion, however,  is  sometimes  called  for  in  the  treatment  of  chronic,  in- 
tractable inflammations  of  the  colon.  In  malignant  diseases  of  the 
latter,  those  which  are  operable  can  be  removed  by  resection  almost  as 
safely  without  preliminary  colotomy  as  with  it.  In  the  inoperable  cases, 
anastomosis  of  the  healthy  gut  above  the  growth,  with  a  similar  por- 
tion below  it,  offers  a  better  solution  of  the  problem  with  almost  as  little 
danger  to  the  patient's  life  as  colotomy.  "VAHien  the  operation  is  called 
for  on  account  of  inflammatory  conditions,  it  should  be  made  as  high 
up  in  the  ascending  colon  as  possible  in  order  to  avoid  the  constant 
escape  of  fluid  faeces  through  it.  When  the  mesocolon  is  long  enough 
for  a  loop  to  be  brought  outside  and  supported  by  a  glass  rod,  the 
Maydl-Eeclus  method  should  be  employed  here  as  upon  the  left  side. 
When  this  is  not  the  case,  one  can  only  bring  as  much  of  the  gut  as 
possible  up  into  the  wound  and  suture  it  to  the  skin.  This,  of  course, 
will  not  produce  a  spur  sufficient  to  prevent  the  escape  of  fgecal  matter 
into  the  intestine  below  the  artificial  anus,  but  inasmuch  as  such  escape 
would  necessarily  be  against  the  force  of  gravity,  it  will  not  be  very 
great.  As  colostomy  upon  this  side  is  nearly  always  of  the  temporary 
variety,  no  portion  of  the  gut  should  be  destroyed  in  opening  it,  for  this 
will  increase  the  difficulties  of  closure. 


CHAPTER    XXII 
FOREIGN  BODIES  IX  THE  RECTVM  AND  SIGMOID  FLEXURE 

The  conformations  of  the  rectum  and  sigmoid  flexure  render  them 
peculiarly  liable  to  the  arrest  and  retention  of  foreign  bodies. 

There  are  three  methods  by  which  they  enter  these  cavities:  First, 
by  being  swallowed  and  passed  through  the  intestinal  canal;  second, 
by  their  development  in  some  portion  of  this  tract  and  passage  through 
it  to  the  sigmoid  or  rectum;  third,  by  introduction  through  the  anus. 
Medical  literature  abounds  with  instances  of  foreign  bodies  of  the  most 
varied  and  marvelous  character  foimd  in  these  cavities.  Ale-Jugs,  cham- 
pagne-bottles, segments  of  ball-bats,  needles,  pins,  spools  of  thread, 
pipes,  chain-saws,  screws,  nails,  coins,  bones,  door-knobs,  cows'  horns, 
pocket-books,  medicine  glasses,  and  hundreds  of  other  articles  have  been 
found  in  the  rectum  and  sigmoid. 

Physiological  Causes  predisposing  to  the  Formation  of  Foreign  Bodies 
in  the  Intestinal  Canal. — These  depend  upon  altered  or  deficient  secre- 
tions from  the  intestinal  glands,  the  liver,  or  the  pancreas.  Patients 
differ  in  regard  to  the  habitual  condition  of  the  contents  of  the  intes- 
tine; in  some  they  are  always  more  or  less  hard  and  dry,  while  in  others 
they  are  always  soft  or  fluid.  These  conditions  depend  largely  upon  the 
habits  of  the  individual,  upon  his  diet,  and  sometimes  upon  his  tem- 
perament. Those  who  live  in  limestone  regions  and  drink  the  hard 
alkaline  water  are  liable  to  the  formation  of  calcareous  masses  in  the 
intestine.  "VHiere  the  intestinal  contents  are  habitually  dry  and  hard, 
it  is  very  easy  for  a  small  foreign  substance  to  form  a  nucleus  around 
which  the  lime  salts  incrustate,  and  thus  form  fjecal  calculi  which  may 
be  arrested  in  any  of  the  saccules  of  the  sigmoid  or  in  the  ampulla  of 
the  rectum;  the  small,  hard  masses  seen  in  certain  individuals  who  are 
the  subjects  of  chronic  constipation  may  also  form  the  nucleus  of  such 
enteroliths.  Eheumatism  and  gouty  diatheses  are  said  to  have  some  in- 
fluence in  their  production.  Old  age  and  prolonged  constipation  are 
the  chief  predisposing  causes. 

Pathological  predisposing  Causes. — Under  this  heading  may  be  enu- 
merated all  the  pathological  conditions  which  tend  to  form  concretions 
894 


FOREIGN   BODIES  IN  THE   RECTUM   AND   SIGMOID   FLEXURE     895 

or  to  narrow  the  rectum  or  sigmoid.  Vitiated  appetites,  such  as  the  eat- 
ing of  clay,  slate-pencils,  chalk,  magnesia,  etc.,  the  formation  and  passage 
of  gall-stones,  and  multiple  adenoids  or  fibromata  of  the  intestine  are 
instances  of  these  predisposing  causes.  Paraplegia  and  spinal  paralysis 
at  any  level  may  be  predisposing  causes  of  the  arrest  of  foreign  bodies 
in  the  rectum  and  sigmoid,  owing  to  the  atony  of  the  muscular  fibers 
of  the  gut  and  consequent  inability  to  pass  these  bodies  out  of  the 
intestinal  canal.  Poulet  says  that  "  paresis  "  of  the  intestine  plays  an 
important  role  in  the  production  of  constipation  and  consequent  arrest 
of  foreign  bodies.  Stricture  of  the  gut  at  any  level  may  also  be  such 
a  cause,  but  the  arrest  of  stercoral  masses  above  a  stricture  of  the  rec- 
tum or  sigmoid  could  scarcely  be  considered  under  the  head  of  foreign 
bodies.  Hernias  may  also  act  in  the  same  way,  and  such  a  condition 
should  always  be  looked  upon  as  a  serious  complication  when  bodies 
of  unusual  size  are  known  to  have  been  swallowed.  Abdominal  tu- 
mors also  may  be  said  to  increase  the  probability  of  arrest  of  foreign 
bodies  while  passing  through  the  intestinal  canal,  but  there  is  no  re- 
corded instance  in  which  they  have  actually  done  so. 

Anatomical  predisposing  Causes. — In  addition  to  the  coarctations  at 
the  anus  and  at  the  junction  of  the  rectum  and  sigmoid,  unusual  devel- 
opment of  the  folds  of  Houston,  the  crypts  of  Morgagni,  and  the  diver- 
ticuli  sometimes  found  in  the  large  intestine  are  predisposing  causes 
to  the  arrest  of  foreign  bodies;  displacements  and  adhesions  of  the 
sigmoid  or  transverse  colon,  hypertrophy  and  spasm  of  the  external 
sphincter,  may  also  be  classed  in  this  category. 

Bodies  which  have  been  Swallowed. — Generally  there  is  some  knowl- 
edge upon  the  part  of  the  patient  of  having  swallowed  such  objects, 
yet  sometimes,  especially  in  children,  the  fact  may  have  escaped  their 
memories,  or  they  may  have  been  entirely  unconscious  of  such  an  acci- 
dent. The  first  intimation  they  have  of  the  condition  arises  from  the 
irritation  and  sufl'ering  due  to  the  presence  of  the  body.  The  author 
has  recently  seen  3  cases  of  the  most  marked  suffering  due  to  the  arrest 
of  foreign  bodies  at  the  anus,  where  the  patients  were  entirely  ignorant 
of  having  swallowed  any  such  substances.  One  of  these  cases  was  in  a 
gentleman  from  Boston,  who  was  seized  on  a  Friday  with  sharp,  cutting 
pains  in  his  rectum.  His  medical  attendant,  without  examination,  im- 
mediately surmised  that  he  was  suffering  from  fissure  or  ulcerating  hem- 
orrhoids, inasmuch  as  some  blood  had  appeared,  and  prescribed  a  sooth- 
ing ointment  for  his  relief.  After  having  visited  two  other  physicians 
in  the  mean  time,  neither  of  whom  made  a  careful  examination,  he 
consulted  the  author  on  the  following  Tuesday;  he  was  under  the  influ- 
ence of  opiates,  and  yet  suffered  intensely  with  pain  in  his  rectum. 
An  ocular  examination  showed  congestion  about  the  anus  and  slight 


896  THE   ANUS,   RECTUM,   AND   PELVIC  COLON 

protrusion  of  small  ha-inorrhoids.  These,  however,  did  not  account  for 
his  pain.  An  clt'ort  to  separate  the  margins  of  the  anus  greatly  increased 
his  pain;  upon  attempting  to  introduce  the  finger  into  the  anus  it 
came  in  contact  with  a  hard,  angular  body,  pressure  upon  which  gave 
the  patient  such  agony  that  it  was  necessary  to  desist  until  he  had  been 
anaesthetized.  After  chloroform  was  administered,  the  finger  was  intro- 
duced alongside  of  the  foreign  body,  the  sphincter  was  stretched,  and 
there  was  removed  from  the  rectum  the  breast-bone  of  a  snipe,  kite- 
shaped,  with  three  sharp  points,  which  had  been  grasped  by  the  sphinc- 
ter so  that  thfv  all  punctured  the  mucous  membrane.  Infection  and 
suppuration  had  set  in,  but  no  burrowing  had  taken  place,  and  under 
antiseptic  treatment  the  parts  healed  rapidly.  The  patient  had  no 
recollection  of  having  eaten  a  bird  of  any  kind  except  a  snipe,  some  eight 
weeks  previous  to  the  time  of  his  accident. 

In  the  second  case  the  outer  hull  of  an  apple-seed  was  arrested  in 
one  of  the  cr}-pts  of  Morgagni,  and  grasped  tightly  by  the  sphincter. 
He  also  had  consulted  a  physician,  who  told  him  he  had  fissure.  It  is 
not  intended  to  relate  a  number  of  such  cases  in  this  connection;  a 
brief  outline  of  these  two  histories  has  been  given  to  impress  upon  the 
reader  the  importance  of  local  examination  in  such  cases,  and  to  illus- 
trate how  much  suffering  can  be  produced  by  the  arrest  of  insignificant 
foreign  bodies  at  this  point. 

When  large  bodies  are  swallowed  accidentally  the  patient  is  always 
aware  of  the  fact,  and  generally  seeks  for  assistance  or  advice  imme- 
diately. If  the  bodies  are  comparatively  smooth  and  of  a  size  which 
allows  them  to  be  swallowed  without  great  difficulty,  we  may  trust 
with  fairly  good  confidence  that  they  will  pass  through  the  intestinal 
canal,  at  least  as  far  as  the  sigmoid  or  rectum.  Arrest  at  the  csecum 
may  occur,  but  this  is  rare.  "What  passes  the  pylorus  will  usually  pass 
through  this  aperture. 

The  length  of  time  which  a  foreign  body  takes  to  pass  from  the 
stomach  to  the  rectum  is  most  variable.  A  case  has  been  reported  in 
which  a  plate  of  teeth,  swallowed  at  night,  was  found  in  the  anus 
the  next  morning.  Another  was  treated  in  which  the  tin  tag  off  a  piece 
of  tobacco  was  swallowed,  and  did  not  appear  until  found  in  the  rectum 
almost  three  months  later;  in  this  case,  the  fact  of  the  tin  tag's  having 
been  swallowed  at  all  was  doubted,  and  yet  the  child  was  watched  care- 
fully during  the  whole  period,  and  her  rectum  was  examined  regularly 
for  the  first  two  weeks  without  discovering  any  evidence  whatever  of 
the  foreign  body.  Eighty-four  days  after  the  accident  the  author  was 
called  to  her  on  account  of  griping  pains  in  her  abdomen  and  inability 
to  move  her  bowels.  Introduction  of  the  finger  into  the  rectum  showed 
the  tin  tag  squarely  across  the  anus  and  forming  a  complete  metallic 


FOREIGN  BODIES  IN  THE  RECTUM  AND  SIGMOID  FLEXURE    897 

occlusion,  with  its  five  points  sticking  into  the  mucous  membrane  and 
the  sphincter  grasping  it.  The  parents  claimed  the  recovered  tag  as  a 
family  relic,  and  still  retain  it. 

Another  illustration  of  how  long  these  bodies  may  remain  in  the 
rectum  and  continue  to  produce  irritation,  and  yet  not  be  discovered, 
is  that  related  by  Ackers  (London  Lancet,  1898,  vol.  ii,  p.  690).  The 
patient  consulted  him,  complaining  of  the  frequent  desire  to  go  to 
stool,  but  inability  to  accomplish  it  on  account  of  a  sharp,  pricking 
pain  inunediately  following  any  effort  to  relieve  his  bowels.  He  said 
that  he  had  suffered  from  this  pain  for  thirty  years;  sometimes  it  was 
more  severe  and  sometimes  less;  when  the  fgecal  mass  was  hard,  it  was 
almost  impossible  for  him  to  bear  it;  when  the  passages  were  fluid,  the 
pain  was  not  so  severe,  but  that  it  had  always  been  present,  and  that 
he  felt  it  whenever  he  sat  in  certain  positions.  He  had  consulted  physi- 
cians with  regard  to  the  trouble,  and  had  been  told  that  it  was  simply  a 
fissure  or  haemorrhoids,  and  soothing  ointments  had  been  prescribed. 
Upon  examination.  Ackers  found  a  long  bent  pin  which  was  stuck  into 
the  tissues  just  above  the  internal  sphincter,  and  extended  downward 
and  backward  almost  to  the  skin,  while  the  head,  like  a  crank,  extended 
quite  across  the  anal  aperture;  thus,  whenever  the  faecal  mass  passed  over 
this,  it  carried  the  point  downward  and  backward,  producing  a  scratch- 
ing, as  well  as  a  pricking  pain.  Without  any  anaesthetic,  Ackers  re- 
moved the  pin,  and  the  patient  was  immediately  relieved.  This  case 
is  quoted  because  it  is  reported  by  a  man  entirely  worthy  of  belief,  and 
yet  it  is  almost  incomprehensible  that  a  pin  should  remain  in  the  in- 
testinal canal  for  thirty  years  without  rusting  and  being  dissolved 
by  the  secretions  of  that  canal.  Admitting  this  as  a  possibility,  it  is 
just  as  incomprehensible  that  any  body  should  penetrate  the  mucous 
membrane  and  remain  in  this  position  for  any  considerable  period  of 
time  without  causing  infection,  abscess,  fistula,  or  some  perirectal  in- 
flammation. There  seem  never  to  have  been  any  such  complications 
in  this  case.  The  length  of  time  intervening  between  swallowing  a 
foreign  body  and  finding  it  in  the  rectum  or  sigmoid  does  not  indicate 
how  long  it  has  been  arrested  at  this  point,  for  it  may  have  been  lodged 
in  some  fold  or  diverticulum  of  the  intestine,  dislodged  and  arrested 
again  and  again  in  its  passage  through  the  canal;  but  such  cases  as 
Morton's  (Penn.  Hosp.  Eepts.,  1880,  p.  335),  in  which  the  foreign  body 
was  known  to  have  been  in  the  rectimi  for  fou:  years,  and  Ogle's  (Proc. 
Eoy.  Med.  and  Chir.  Soc,  London,  1861-'64,  p.  267),  in  which  a  stick 
remained  in  the  rectum  four  months,  gives  one  some  idea  of  the  possi- 
bilities in  these  cases. 

The  cases  which  interest  us  most,  and  which  will  give  the  practitioner 
more  trouble,  are  those  in  which  the  foreign  bodies  have  been  swallowed 
57 


898  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

unconsciously  or  thoughtlessly,  and  in  wliich  the  sjanptoms  of  arrest 
come  on  later.  Fruit-seeds,  coins,  false  teeth,  pins,  buttons,  etc.,  fre- 
quently pass  through  the  alimentary  tract  and  become  arrested  in  the 
sigmoid  or  rectum.  The  author  once  removed  from  the  rectum  of  a  lady 
a  mass  of  grape-seeds  almost  as  large  as  a  foetal  head,  that  weighed 
22  ounces.  Examination  with  the  speculum  showed  that  the  rectal 
mucous  membrane  was  studded  all  over  with  little  ulcerated  spots,  evi- 
dently the  result  of  punctures  from  the  points  of  the  seeds.  The  pa- 
tient had  suffered  from  a  watery  diarrhoea  that  might  easily  have  misled 
one  who  was  not  in  the  habit  of  making  local  examinations  in  all  cases 
of  diarrhoea  and  constipation.  Poulet  {op.  cit.,  p.  304)  relates  a  case  in 
which  60  snails  were  found  in  the  patient's  rectum,  and  the  author  has 
seen  2  cases  in  which  plates  of  false  teeth  were  swallowed  and  lodged, 
1  in  the  sigmoid  and  1  in  the  rectum. 

Enteroliths;  Colproliths;  Faecal  Stones. — Ftecal  concretions  develop 
in  those  portions  of  the  intestine  where  the  movement  of  the  faecal 
current  is  not  active,  at  the  hepatic  and  splenic  flexures,  the  caBcum,  the 
sigmoid,  and  in  the  ampulla  of  the  rectum.  The  vermiform  appendix 
is  also  a  frequent  site  for  their  formation,  but  they  rarely  pass  out  from 
this  organ.  They  are  of  a  firm  consistence,  and  sometimes  form  real 
enteroliths. 

Leichtenstern  describes  three  varieties:  First,  concretions  of  a  stony 
consistence,  brown  in  color,  and  composed  of  phosphates  of  magnesium 
and  calcium.  They  are  formed  by  concentric  layers  around  foreign 
bodies,  such  as  inspissated  masses  of  faeces,  ascarides,  small  pieces  of 
bone,  fruit-seeds,  etc.  Second,  concretions  of  light  specific  gravity  com- 
posed largely  of  undigested  vegetable  matter.  Third,  chemical  stones, 
or  those  resulting  from  the  protracted  use  of  calcium  and  magnesium 
carbonates,  bicarbonate  of  soda,  salol,  and  other  drugs.  This  last  variety 
is  not  frequent,  but  they  may  acquire  enormous  size,  and  even  cause 
obstruction  of  the  intestine.  They  become  dislodged  from  the  points 
at  which  thev  form,  pass  downward,  and  are  arrested  in  the  sigmoid  or 
rectum.  A  very  interesting  specimen  of  this  kind  was  shown  me  by  a 
member  of  my  class  during  the  winter  of  1898.  He  was  called  to  see 
an  old  lady  sufl^ering  with  intense  pain  in  the  right  inguinal  region. 
Upon  examination  he  felt  a  mass  about  the  size  of  a  cricket  ball  or  larger. 
There  was  no  fluctuation  and  no  rise  in  temperature.  The  woman  said 
the  lump  had  been  there  a  long  time,  and  thought  it  had  nothing  to 
do  with  her  pain.  He  administered  a  mild  laxative  and  ordered  large 
rectal  enemata,  and  called  to  see  the  patient  three  days  later.  Xot- 
withstanding  the  fact  that  no  unusual  mass  or  solid  ftecal  matter  had 
passed,  the  lump  which  he  felt  before  had  absolutely  disappeared,  and 
the  patient  complained  of  a  weight  in  her  back  and  pressure  at  the 


FOREIGN  BODIES  IN  THE  RECTUM  AND  SIGMOID   FLEXURE    899 

lower  end  of  the  rectum.  An  examination  with  tlie  finger  in  the  rectum 
elicited  a  mass  hard  as  a  rock  and  so  large  that  it  was  impossible 
to  remove  it  without  divulsing  the  sphincter.  The  body  when  shown 
had  every  appearance  of  stone  formation;  it  was  4  inches  long  by  2f 
wide,  rounded  at  both  ends  and  sides,  and  formed  an  elliptical,  smoothly 
polished  body.  The  woman  gave  no  history  of  ever  having  swallowed 
any  foreign  body,  and  there  was  no  possibility  of  its  having  passed  from 
the  bladder  into  the  rectum,  as  that  viscus  was  absolutely  healthy. 
Evidently  it  had  been  formed  in  the  cfficum  or  appendix,  and  being  set 
free  it  was  carried  along  the  canal  until  it  lodged  in  the  rectum.  Gant 
has  also  reported  an  interesting  case  of  this  kind  (Proceed.  Amer. 
Proctologic.  Society,  1900). 

Foreign  Bodies  introduced  into  the  Rectum. — When  foreign  bodies 
have  been  introduced  into  the  rectum  through  the  anus,  there  is  nearly 
always  a  knowledge  of  such  condition  when  the  patient  seeks  advice. 
Unfortunately,  the  purposes  for  which  these  bodies  are  introduced  are 
of  such  a  nature  that  the  patient  will  not  admit  the  accident  until  he 
is  forced  to  do  so  by  great  pain  and  dire  distress.  Such  introduction 
may  be  intentional  or  accidental.  Ball,  quoting  Hamilton,  says  that 
the  inhabitants  of  Balason,  on  the  Bay  of  Bengal,  were  in  the  habit 
of  introducing  into  the  rectum  after  defecation  small  bodies  of  clay, 
and  removing  them  at  the  next  stool.  This  was  done  with  a  view  of 
preventing  further  movements  during  the  day,  or  it  may  have  been 
done  for  hygienic  purposes,  but  there  is  no  history  given  of  any  of 
these  bodies  having  been  retained  (A  New  Account  of  the  West  Indies, 
London,  1708). 

In  some  countries  foreign  bodies  are  introduced  into  the  rectum  as 
a  means  of  punishment,  but  usually  they  are  introduced  for  the  relief 
of  certain  symptoms,  for  excitation  of  passion,  for  the  purposes  of 
concealment,  or  by  accident. 

Foreign  Bodies  introduced  for  the  Relief  of  Certain  Symptoms. — A 
large  number  of  foreign  bodies  have  been  found  in  the  rectum,  intro- 
duced by  ignorant  people  for  the  purpose  of  relieving  some  pathological 
condition.  Some  have  used  these  bodies  to  provoke  a  movement  of  the 
bowel  and  thus  remedy  an  obstinate  constipation;  others  have  intro- 
duced them  with  a  view  of  controlling  a  diarrhceal  discharge. 

One  theoretical  individual,  who  evolved  the  idea  that  the  less  matter 
he  discharged  from  his  bowel  the  less  food  he  would  need  in  order  to 
live,  introduced  a  stone  jar  into  his  rectum  to  avoid  fascal  movements. 
It  was  with  great  difficulty  and  pain  that  the  body  was  removed.  Moran 
reports  the  case  of  a  pious  monk,  who  suffered  with  a  severe  colic,  and 
thought  to  relieve  the  same  by  pouring  a  bottle  of  Hungarian  water 
into  the  rectum,  and  so  arranged  himself  that  the  water  would  flow 


900  THE   ANUS,   RECTUM,   AND   PELVIC   COLON 

little  by  little  into  the  intestine.  The  bottle  slipped  from  his  grasp, 
escaped  into  the  rectum,  and  resulted,  not  in  his  relief  but  in  the  in- 
crease of  his  colic,  and  an  inliauunation  which  threatened  his  life.  After 
many  attempts  by  forceps  and  other  instruments  to  remove  the  bottle, 
it  was  finally  dragged  out  by  the  hand  of  a  small  boy  who  was  induced 
to  thus  relieve  the  good  monk. 

Where  these  bodies  are  introduced  for  legitimate  purposes,  such  as 
those  mentioned,  and  escape  from  the  grasp  of  the  patient,  there  is  gen- 
erally no  delay  in  consulting  a  physician,  and  little  irritation,  inflam- 
mation, or  swelling  complicates  their  removal,  but  the  large  majority  of 
these  bodies  are  introduced  into  the  rectum  for  other  purposes  or  by 
accident. 

Foreign  Bodies  introduced  for  Purposes  of  Concealment. — The  rectum 
has  long  been  known  as  a  means  made  use  of  by  thieves  and  criminals  for 
the  concealment  of  stolen  articles  or  instruments  for  crime;  jewelry, 
coins,  money,  gems,  false  keys,  etc.,  have  been  concealed  in  the  rectum, 
and  found  there,  sometimes  after  death  and  sometimes  during  life. 

The  well-kno^\Ti  report  of  Closmadeuc  (Society  of  Surgery,  May  15, 
1861)  describes  a  case  of  a  criminal  from  whose  transverse  colon  there 
was  removed  a  sort  of  box  or  necessaire,  covered  with  the  omentum  of 
a  lamb,  and  containing  coins,  several  small  saws,  and  numerous  instru- 
ments for  effecting  his  escape  from  prison.  This  article  had  been  intro- 
duced into  his  rectum  for  the  purpose  of  concealment,  and  had  grad- 
ually worked  its  way  upward  into  the  position  in  which  it  was  found, 
where  it  produced  peritonitis  and  the  subsequent  death  of  the  patient. 
There  are  a  large  number  of  cases  on  record  of  this  kind,  and  a  knowl- 
edge of  such  facts  is  important  to  prison  physicians  as  well  as  to  the 
police. 

Foreign  Bodies  introduced  into  the  Bectum  hy  Accident. — It  is  a 
rare  thing  that  foreign  bodies  are  introduced  by  simple  accidents,  such 
as  a  fall  on  pointed  sticks  or  on  the  palings  of  fences,  which  penetrate 
the  anus  and  are  broken  off  and  left  there.  An  interesting  case  of  this 
kind  is  reported  by  Hawkins  (Indian  Lancet,  1898,  vol.  i,  p.  417),  in 
which  an  Italian,  dancing  an  obscene  dance  around  a  tumbler  set  on 
the  floor,  slipped  and  fell  upon  this  object.  The  tumbler  broke,  and 
about  I  of  its  bowl  penetrated  the  man's  anus  and  lodged  in  the  rec- 
tum. The  patient  reported  having  had  a  great  haemorrhage,  but  at 
the  time  that  he  entered  the  hospital  this  had  ceased.  Two  points  of 
the  broken  tumbler  had  penetrated  deeply  into  the  perirectal  tissues, 
and  it  was  impossible  to  withdraw  the  object  until  the  doctor  had 
excised  the  coccyx  and  split  the  rectum  upward  for  about  2  inches, 
thus  affording  room  to  remove  it  backward  and  disengage  the  points 
penetrating  the  tissues  in  front. 


FOREIGN  BODIES  IN  THE  RECTUM  AND  SIGMOID  FLEXURE    901 

Delbet  (Gaz.  hebdom.,  Paris,  1877,  p.  1069)  was  the  first  to  make 
use  of  Amussat's  suggestion  to  cut  out  the  coccyx  in  order  to  gain 
space  for  the  removal  of  foreign  bodies  from  the  rectum.  Buffet  (Nor- 
mandie  med.,  April,  1894)  has  also  employed  this  method.  It  indicates 
a  very  practical  procedure,  which  may  be  adopted  in  cases  of  large 
bodies,  the  lower  ends  of  which  penetrate  the  tissues  about  the  mar- 
gin of  the  anus. 

Camper  (Prix  de  I'acad.  de  chirurg.,  t.  xii,  p.  165)  reports  the  case 
of  a  man  who  fell  from  a  considerable  height  upon  the  sharp  point  of 
a  piece  of  wood  which  penetrated  his  anus  and  entered  the  bladder, 
resulting  in  a  urinary  fistula.  The  pieces  were  removed  from  the  rectum 
about  one  year  afterward,  coated  with  a  calcareous  deposit  from  the 
urine,  and  the  patient  made  a  good  recovery. 

The  history  of  the  brutal  murder  of  Edward  II,  by  the  introduction 
of  a  red-hot  iron  into  his  rectum,  is  quoted  in  many  books  as  an  in- 
stance of  foreign  body  in  this  organ.  Its  bearing  in  this  connection 
is  not  apparent,  but  a  number  of  cases  have  been  reported  in  which 
individuals  have  had  foreign  bodies  introduced  into  their  recta,  either 
as  a  practical  Joke  or  in  revenge  for  some  offense. 

An  instance  of  this  kind  is  reported  by  Matienzo  (ISTew  York  Med. 
Eecord,  1898,  vol.  liii,  p.  533),  in  which  a  man,  during  a  drunken  de- 
bauch, had  shoved  into  his  rectum  a  piece  of  smooth  wood,  spherical 
at  the  top,  but  rough  and  serrated  at  the  bottom,  26  centimeters  (10| 
inches)  long  and  6  centimeters  (2|  inches)  in  diameter.  The  patient 
began  to  suffer  from  pain  in  his  abdomen  immediately  after  recovering 
from  his  debauch,  but  never  realized  that  any  foreign  body  was  present 
until  he  consulted  a  physician  sixteen  days  afterward,  when  the  body 
was  found,  the  upper  end  being  felt  through  the  abdominal  wall  to  the 
left  of  the  umbilicus.  It  was  removed  by  traction  on  the  lower  end, 
and  pressure  from  above. 

Under  this  head  may  also  be  mentioned  those  distressing  and  de- 
testable cases  in  which  foreign  bodies  have  been  used  for  the  purposes 
of  exciting  passion  in  degraded  and  depraved  individuals,  and  which 
have  accidentally  slipped  into  the  rectum.  Perhaps  the  majority  of  the 
large  foreign  bodies,  such  as  bottles,  sticks,  lamp  chimneys,  pipe-stems, 
etc.,  found  in  the  rectum  have  occurred  in  this  way.  It  is  usually 
in  old  men  whose  desires  have  survived  their  virile  powers,  and  any 
explanation  which  they  may  give  of  these  accidents  will  ordinarily  be 
utterly  unreliable  and  unworthy  of  belief.  In  such  cases  the  infundib- 
ular shape  of  the  anus,  the  evidences  of  traumatism,  and  the  irritation 
of  the  parts  will  generally  give  a  good  idea  of  the  moral  character  of 
the  patient,  and  point  to  the  real  cause  of  suffering.  Under  such  cir- 
cumstances, and  with  guilty  consciences,  patients  trust  to  the  illusory 


902  THE  ANUS,   RECTUM,  AND  PELVIC  COLON 

hope  that  the  bodies  will  be  passed  spontaneous^.  They  do  not,  there- 
fore, consult  a  physician  until  their  sufferings  have  become  unbearable 
and  their  condition  often  desperate,  if  not  absolutely  beyond  relief. 

Some  remarkable  cases  have  occurred  in  which  large  bodies  have 
remained  in  the  intestine  for  considerable  periods  of  time  without  per- 
foration, and  have  worked  their  way  upward  until  they  were  beyond 
the  reach  of  the  hand  or  of  instruments  for  their  removal  through  the 
rectum. 

Poulet,  quoted  by  Kelsey,  reports  a  case  of  a  farmer  who  introduced 
a  piece  of  wood,  over  13  centimeters  (+  5  inches)  long  and  nearly  3 
centimeters  (-f-  1  inch)  in  diameter,  roughened  and  serrated  at  its  broken 
end,  into  the  rectum.  All  attempts  to  remove  it  failed,  and  it  passed 
up  into  the  sigmoid,  and  could  be  made  out  apparently  as  high  as  the 
floating  ribs.  After  thirty-one  days,  during  which  enemata  and  cathar- 
tics were  given  with  greater  or  less  regularity,  the  object  was  passed 
by  the  rectum,  and  proved  to  be  the  end  of  a  bean-pole.  The  patient 
recovered  without  any  serious  difficulty. 

Pierra  (Indian  Med.  Eecord,  1896,  p.  131)  reported  the  case  of  a 
man  who  passed  a  roughened  stick  9^  inches  long  by  1^  inch  in  diameter 
into  his  rectum.  This  was  extracted  without  any  permanent  damage 
having  been  done. 

The  results  are  not  always  so  favorable.  Several  instances  have  been 
reported  in  which  the  body  penetrated  the  bladder,  leaving  recto-vesical 
fistula;  others  in  which  the  peritoneum  was  perforated,  causing  death; 
and  very  many  in  which  rectitis,  ulceration,  periproctitis,  fistula,  and 
sepsis  have  followed  the  introduction  of  foreign  bodies  into  the  rectum. 

Symptoms. — The  symptoms  in  these  cases  are  subjective  and  objec- 
tive. 

Subjective  Symptoms. — Ordinarily  the  patient  will  consult  a  physi- 
cian for  spnptoms  which  may  be  referred  to  simple  intestinal  or  rectal 
complaints,  such  as  constipation,  diarrhoea,  hsemorrhage  at  stool,  tenes- 
mus, the  passage  of  mucus,  slight  passages  of  blood,  etc.  If  the  foreign 
body  has  entered  the  rectum  through  the  mouth,  or  through  having 
been  formed  in  the  intestine  unknown  to  the  patient,  or  if  it  has  been 
introduced  into  the  anus  for  legitimate  purposes,  the  patient  will  gen- 
erally give  a  true  account  of  his  condition,  not  biased  by  any  embar- 
rassment or  shame,  and  the  correct  diagnosis  may  be  easily  made.  "\Miere 
the  body  is  small  and  arrested  in  one  of  the  folds  of  Houston  or  the 
crypts  of  Morgagni,  the  pain  may  be  more  or  less  constant,  or  it  may 
only  appear  when  straining  at  stool.  This  will  depend  largely  upon  the 
shape  of  the  body;  if  it  is  a  round,  smooth  body,  it  will  cause  little  suffer- 
ing. If  it  is  an  irregular  body,  with  sharp  edges  or  points,  it  will  give  pain 
upon  motion  and  efforts  at  defecation;  if  the  mucous  membrane  or  the 


FOREIGN   BODIES  IN  THE  RECTUM  AND  SIGMOID   FLEXURE    903 

walls  of  the  rectum  have  been  penetrated,  this  pain  will  be  more  or  less 
constant;  especially  will  this  be  so  if  the  foreign  body  be  grasped  by  the 
sphincter  muscle,  as  in  cases  where  a  sharp  body,  such  as  a  fish-bone  or 
pin,  has  lodged  at  the  anus.  A  case  with  all  these  symptoms  has  been 
reported  by  Billingslea  (Southern  Med.  and  Surg.  Jour.,  August,  1856, 
p.  148),  in  which  there  was  an  arrest  at  the  juncture  of  the  rectum  and 
sigmoid  of  a  piece  of  bone  which  the  patient  had  no  recollection  what- 
ever of  having  swallowed.  In  other  cases  the  foreign  body  may  present 
symptoms  of  fissure  in  ano,  with  nervous  and  constitutional  disturbances. 
A  small  piece  of  egg-shell  arrested  within  the  grasp  of  the  sphincter 
has  given  rise  to  such  symptoms  in  a  case  reported  by  Whitehead  (Trans- 
actions of  the  Colorado  Med.  Soc,  Denver,  1874,  p.  42). 

If  the  body  be  large  and  its  edges  smooth  or  round,  the  pain  will  not 
be  acute,  but  a  dull,  heavy,  aching  pain,  increased  upon  movement  or 
jarring,  bending  down,  efforts  at  stool,  and  sometimes  the  sitting  posture, 
through  pressure  upward  upon  the  perinseum  and  downward  upon  the 
abdomen,  will  give  great  discomfort.  The  fact  that  these  patients  have 
numerous  stools  during  the  day  of  thin,  watery  fluid  may  lead  the  physi- 
cian to  suppose  it  is  a  case  of  diarrhoea. 

Spasm  of  the  sphincter  and  levator  ani  muscles  are  often  present 
with  foreign  bodies  in  the  rectiun.  These  spasms  are  increased  by 
whatever  act  or  motion  causes  the  foreign  body  to  press  upon  the  mus- 
cles. Sometimes  the  spasm  occurs  upon  bending  over  or  sitting  down 
upon  the  commode;  at  other  times,  where  the  muscles  and  membranes 
are  penetrated  by  sharp  points,  the  spasm  is  continuous. 

Constipation  is  frequently  observed,  but  this  is  a  relative  term  and 
not  much  can  be  gathered  from  it  as  a  symptom.  When  symptoms  of 
obstruction  appear,  such  as  swelling  of  the  abdomen,  nausea,  vomiting, 
hiccough,  high  temperature,  rapid  pulse,  etc.,  the  case  becomes  very 
grave.  Genito-urinary  symptoms  are  a  very  frequent  complication  of 
foreign  bodies  in  the  rectum.  Sometimes  these  s3anptoms  so  predom- 
inate that  the  physician  is  led  in  the  beginning  to  consider  those  organs 
as  the  main  cause  of  offense,  and  to  search  them  in  vain  for  some  con- 
dition to  account  for  the  suffering.  Dysuria,  anuria,  cystitis,  neuralgia 
of  the  testicles,  pain  in  the  scrotum  and  along  the  tract  of  the  crural 
nerves,  are  frequent  complications.  These  are  due,  first,  to  mechanical 
pressure  upon  the  parts  by  the  foreign  body  and,  second,  to  reflex  action. 

When  the  body  has  remained  for  some  time  in  the  intestine  and 
produced  much  irritation,  grave  constitutional  symptoms,  such  as  cold 
sweats,  fainting,  convulsions,  and  high  temperature,  may  supervene. 
Hawkins  (The  Indian  Lancet,  1898,  p.  417)  reported  an  interesting 
case  of  this  kind  in  which  a  glass  tumbler  was  introduced  into  the 
rectum  with  a  view  of  overcoming  diarrhoea,  and  was  broken  in  the 


90i  THE  ANUS,  RECTUM,  AND   PEL^^C  COLON 

efforts  of  the  patient  to  extract  it.  The  doctor  was  consulted  after  the 
patient  had  suffered  for  some  days,  the  symptoms  being  those  of  intes- 
tinal obstruction;  he  succeeded  in  removing  the  glass  and  relieving  the 
patient. 

Objective  Symptoms. — The  physical  symptoms  which  are  produced 
b}-  a  foreign  body  in  the  rectum  are  very  vague  and  indefinite,  espe- 
cially if  the  body  is  formed  in  the  intestiaal  canal,  or  has  entered 
through  the  mouth,  and  thus  approaches  the  rectum  from  above.  Ordi- 
narily ocular  observation  will  reveal  nothing  to  indicate  the  nature  of 
the  patient's  disorder.  There  may  be  a  protrusion  of  hfemorrhoidal 
tumors,  a  slight  discharge  of  pus,  a  moist  condition  about  the  anus,  or 
sometimes  a  prolapse  of  the  mucous  membrane  of  the  rectum,  but  all 
of  these  conditions  are  compatible  with  simple  inflammatory  diseases 
of  the  rectum,  and  are  not  necessarily  connected  with  foreign  bodies. 

If  the  latter  are  introduced  through  the  anus,  there  may  be  some 
wound,  crack,  or  fissure  of  the  parts  indicating  the  cause  of  the  trouble, 
but  it  is  remarkable  what  large  bodies  can  be  parsed  through  the  anus 
without  producing  any  apparent  lesions.  Poulet  says  haemorrhage  of 
moment  rarely  if  ever  occurs  except  when  leeches  have  been  introduced 
into  the  anus. 

If  the  foreign  body  is  introduced  by  accident,  such  as  falls  upon 
sharp  objects,  the  woimd  of  a  bayonet,  or  impaling  upon  a  stake,  con- 
siderable hfemorrhage  may  follow  immediately,  and  yet  at  the  time  of 
the  examination  by  the  surgeon  no  bleeding  may  be  present.  In  certain 
eases,  where  the  foreign  body  is  ver}-  large,  a  bulging  of  the  perinaeum 
may  be  felt  and  seen;  when  such  is  the  case  the  anus  generally  protrudes 
to  a  certain  extent,  and  the  hemorrhoidal  vessels  are  congested  and 
swollen,  forming  a  sort  of  a  nipple  upon  the  distended  perinaeum. 

Diagnosis. — The  only  reliable  means  of  diagnosis  in  these  cases  are 
the  educated  touch  and  the  rectal  tube.  Wliere  the  body  is  low  enough 
down  to  be  felt,  the  finger  is  all  that  is  necessary;  but  when,  as  fre- 
quently occurs,  the  body  has  slipped  beyond  the  reach  of  the  finger, 
or  has  lodged  at  a  point  so  high  up  that  it  can  not  be  touched  by 
digital  examination,  recourse  must  be  had  to  a  rectal  speculum  of  some 
sort. 

The  pneumatic  proctoscope  and  the  simple  rectal  tube  are  the  most 
useful  instruments  for  this  purpose,  and  they  serve  also  as  a  means 
through  which  to  grasp  the  foreign  body  and  drag  it  down.  With  these 
instruments  it  is  possible  to  see  and  clearly  diagnose  the  presence  and 
nature  of  the  body  up  to  the  lower  end  of  the  descending  colon.  In 
those  cases  in  which  it  is  arrested  in  one  of  the  cr\'pts  of  Morgagni,  the 
fenestrated  speculum  used  in  connection  with  a  laryngeal  mirror  is  of 
great  value. 


FOREIGN  BODIES  IN  THE  RECTUM  AND   SIGMOID   FLEXURE     905 

When  the  body  is  arrested  above  a  stricture  or  hypertropliied  valve 
of  Houston,  a  bent  probe  or  searcher  may  be  necessary  to  make  this 
search. 

Complications. — The  complications  or  accidents  associated  with  for- 
eign bodies  are  very  numerous,  and  depend  largely  upon  the  character 
of  the  body,  the  method  of  its  introduction,  and  the  amount  of  manipu- 
lation and  traumatism  in  efforts  to  expel  or  withdraw  it. 

In  spontaneous  expulsion  of  small  foreign  bodies,  such  as  bones,  pins, 
seeds,  needles,  etc.,  there  may  be  wounding  or  tearing  of  the  mucous 
membrane  at  any  point  of  the  sigmoid  or  rectal  tract.  Frequently  these 
bodies  produce  only  a  slight  scratch  of  the  parts,  cause  some  little  pain, 
and  the  symptoms  rapidly  disappear.  Sometimes,  however,  the  injury 
may  be  more  extensive.  The  patient  may  have  considerable  haemor- 
rhage, as  from  a  hsemorrhoid,  and  there  may  result  an  acute  fissure, 
and  an  ulcerated  or  inflammatory  condition  about  the  margin  of  the 
anus. 

This  spontaneous  expulsion  of  foreign  bodies  from  the  rectum  may 
take  place  after  the  body  has  remained  there  for  comparatively  long 
periods.  Schmidt  (Annals  de  Schmidt,  1862,  vol.  cxiii,  p.  95)  reports 
the  case  of  a  man  who  passed  a  piece  of  wood  5^  inches  long,  after  it 
was  embedded  in  the  rectum  for  thirty-one  days.  The  length  of  time 
which  foreign  bodies  may  rest  in  the  cavity  without  serious  inconve- 
nience has  already  been  discussed,  but  the  longer  they  remain  the  more 
likely  are  they  to  produce  serious  complications.  When  large  they  cause 
congestion,  inflammation,  thickening  of  the  walls  of  the  gut,  ulcera- 
tion, and  sometimes  stricture.  Invagination  or  prolapsus  is  also  said 
to  have  been  produced  by  their  presence  in  the  rectum,  exciting  con- 
stant peristaltic  action  and  straining  at  stool.  Where  the  object  is  of 
an  irregular  nature,  with  sharp  edges  or  points,  the  walls  of  the  gut 
may  be  perforated  and  produce  perirectal  inflammation,  abscess,  and 
fistula.  After  the  removal  of  such  bodies  from  the  rectum,  one  should 
always  carefully  examine  the  parts  to  be  sure  that  no  blind  fistula  has 
been  left  behind. 

Punctures  by  these  bodies  may  cause  localized  suppurative  peritonitis, 
and  yet  not  prove  fatal  on  account  of  the  tendency  of  ISTature  to  shut 
off  such  septic  products  and  enclose  them  in  separate  cavities,  thus  to 
protect  herself  from  general  infection.  The  cases,  however,  in  which 
the  peritoneal  cavity  is  opened  through  gangrene  due  to  pressure  upon 
the  parts  are  sure  to  prove  rapidly  fatal. 

One  other  complication  should  be  noticed,  and  that  is  the  fact  that 
foreign  bodies  that  remain  in  the  rectum  for  considerable  periods  of 
time  may  become  coated  with  calcareous  substances,  generally  phosphate 
of  magnesium  or  lime.    Sometimes  this  coating  may  be  due  to  a  recto- 


906  TEE  AXrS,  RECTUM,  AND   PELVIC   COLON 

vesical  fistula,  and  the  leakage  of  urine  into  the  rectum  (Crummer,  Kel- 
sej'),  and  at  others  it  is  due  to  incrustations  from  the  intestinal  salts. 
Dahlenkampf  (Poulet,  p.  313)  has  reported  a  case  in  which  a  piece  of 
wood  introduced  into  the  rectum  was  thoroughl}-  incrusted  with  a  silvery, 
crystallized  phosphate  of  lime.  The  incrustuig  material  will  aid  in  de- 
ciding the  nature  of  the  injury. 

The  symptoms  and  history  of  foreign  bodies  in  the  rectum  may  exist, 
and  yet  one  may  find  it  impossible  to  determine  their  presence  either 
bv  digital  or  ocular  examination.  This  may  be  due  to  the  fact  that  the 
foreign  body  has  dropped  into  a  diverticulum  of  the  rectimi  or  has  pene- 
trated the  mucous  membrane  and  passed  into  the  surrounding  tissues. 

Cunningham  (Southern  Med.  and  Surg.  Jour.,  Augusta,  188T,  p.  764) 
gives  an  account  of  a  foreign  body  found  in  the  nates  6  inches  or  more 
from  the  anus,  but  which  had  evidently  penetrated  the  wall  of  the  gut 
above  the  internal  sphincter,  and  thus  burrowed  down  in  the  direction 
in  which  it  was  found.  This  was  a  case  in  which  there  was  no  particular 
history  of  a  foreign  bodjr's  having  been  in  the  rectum;  but  the  following 
case  (Phil.  Tr.,  London,  1720-'35,  p.  521)  is  one  in  which  a  distinct 
histor}'  of  the  foreign  body  was  given.  The  patient  had  introduced  a 
fork,  with  its  tines  downward,  into  the  rectum  a  short  time  previous. 
Shame  and  embarrassment  prevented  his  seeking  relief  until  his  agonies 
were  so  great  that  he  could  no  longer  bear  them.  Upon  consulting  a 
physician,  the  latter  found  a  sharp  protrusion  in  the  man's  buttock  some 
distance  from  the  anus,  with  one  of  the  tines  of  the  fork  almost  pene- 
trating the  skin.  An  incision  was  made,  and  the  fork  dragged  through 
this,  leaving  a  complete  fistula,  which  afterward  healed.  Tumey  (Xash- 
ville  Med.  and  Surg.  Jour.,  1883,  p.  261)  and  Hood  (Australasian  Med. 
Gaz.,  1888,  vol.  viii,  p.  285)  have  reported  similar  cases.  In  Hood's,  the 
foreign  body  penetrated  the  rectal  wall,  burrowed  through  the  peri- 
naeimi,  entered  the  scrotum,  and  there  caused  a  scrotal  fistula. 

All  such  cases  give  a  certain  number  of  rectal  symptoms,  or  at  least 
a  history  of  having  suffered  from  rectal  irritation,  although  at  the  time 
at  which  they  consult  the  surgeon  these  may  have  disappeared  and  other 
symptoms  predominate.  Careful  exploration  of  the  rectum  will  fre- 
quently make  plain  obscure  conditions  by  the  discovery  of  small  foreign 
bodies  or  internal  blind  fistulas  through  which  the  foreign  body  has 
passed  into  the  surrounding  tissues. 

Prognosis. — In  general,  one  may  say  that  the  large  majority  of  cases 
of  foreign  bodies  in  the  rectum  end  favorably.  From  reading  the  most 
popular  works  upon  diseases  of  the  rectum,  one  would  judge  that  these 
accidents  never  ended  in  any  other  way  except  when  they  penetrated 
the  peritoneal  cavity.  As  a  matter  of  fact,  however,  there  have  been 
a  number  of  fatal  cases  in  which  this  cavity  was  not  penetrated. 


FOREIGN  BODIES  IN  THE  RECTUM  AND  SIGMOID  FLEXURE    907 

Canton  (Lancet,  1849,  p.  630)  reports  the  case  of  an  old  man  who 
died  from  haemorrhage  brought  about  by  jBish-bones  in  the  rectum.  The 
post  mortem  showed  a  number  of  fish-bones  throughout  the  large  in- 
testine; the  lower  half  of  the  rectum  was  three  times  as  thick  as  normal, 
and  the  mucous  membrane  was  gangrenous  and  deeply  perforated  pos- 
teriorly. Half  a  dozen  of  these  bones  were  entangled  in  the  deeper  area, 
some  of  which  entered  the  hgemorrhoidal  vessels  and  caused  the  haemor- 
rhage. C.  S.  Briggs  (Fashville  Jour,  of  Med.  and  Surg.,  1880,  p.  149) 
records  the  case  of  a  man  who  had  introduced  a  wine-glass  into  his  rec- 
tum, measuring  5  inches  in  circumference  and  2^  inches  in  length,  in 
order  to  control  diarrhoea.  The  foreign  body  was  removed  under  anaes- 
thesia. The  posterior  wall  of  the  rectum  was  lacerated,  and  the  man  lost 
a  large  amount  of  blood.  The  diarrhoea  continued,  and  the  patient  died 
at  the  end  of  one  week.  A  question  here  arises  whether  the  patient 
died  from  the  diarrhoea,  which  did  not  seem  to  be  dangerous  at  the  time 
of  the  operation,  or  whether  it  was  due  to  injury  of  the  rectum,  loss 
of  blood,  and  subsequent  infection.  The  latter  theory  seems  the  most 
probable.  Laroyenne  (Gaz.  med.  de  Lyon,  1867,  p.  49)  has  reported  a 
similar  case  to  this. 

M.  Tillaux  (Bull,  et  memoires  de  chirur.,  Paris,  1877,  p.  532)  gives 
an  interesting  account  of  a  man  who  had  introduced  a  bougie  into  the 
rectum,  and  it  slipped  from  his  grasp.  By  examination  of  the  abdomen 
one  could  feel  the  upper  end  of  the  bougie  in  the  left  iliac  fossa.  The 
patient  developed  an  abscess  in  the  fossa  before  the  bougie;  was  re- 
moved, and  died  the  second  day  after  it.  The  post  mortem  showed 
localized  peritonitis  around  the  sigmoid,  but  no  perforation.  The  rec- 
tum was  healthy,  but  in  the  sigmoid  flexure  there  was  a  large  ulcera- 
tion about  the  size  of  a  50-cent  piece,  which  was  no  doubt  the  point 
where  the  extremity  of  the  bougie  was  arrested  for  the  five  days  dur- 
ing which  it  was  retained.  Stone,  quoted  by  Gibbs  (Western  Lan- 
cet, 1856,  p.  7),  reports  the  case  of  a  man  who  passed  a  tin  cup  into 
his  rectum  for  prolapse.  All  efforts  to  remove  it  were  unsuccessful, 
and  the  patient  died  from  peritonitis  without  puncture,  so  far  as  I  can 
learn. 

Weist  (Indiana  Med.  Jour.,  1873,  p.  17)  has  recorded  a  very  inter- 
esting case  of  a  man  who  had  been  accustomed  to  treat  his  haemor- 
rhoids by  passing  into  his  rectum  a  corn-cob,  2^  inches  long  and  |  of 
an  inch  in  diameter.  To  this  he  had  attached  a  sort  of  a  handle;  one 
day,  upon  its  introduction,  the  handle  broke  off  and  the  corn-cob  slipped 
into  the  rectum.  He  consulted  Weist  sixty  hours  later,  at  which  time 
his  abdomen  was  found  swollen  and  tympanitic,  his  pulse  quick,  and 
he  was  suffering  from  nausea  and  hiccough.  The  foreign  body  could 
be  felt  in  the  sigmoid,  but  it  was  impossible  to  remove  it  through  the 


008  THE  ANUS.   RECTUM,   AND   PELVIC   COLOX 

rectum,  owing  to  its  lying  at  an  angle  and  the  handle  being  caught  in 
one  of  the  folds.  The  patient  died  eighty-four  hours  after  the  intro- 
duction of  the  foreign  body.  The  post  mortem  showed  a  general  peri- 
tonitis. The  corn-cob  projected  1^  inch  through  the  sigmoidal  walls. 
Its  total  length,  with  the  broken  handle,  was  -1  inches.  This  case  has 
been  quoted  somewhat  at  length  in  order  to  bring  out  the  fact  that 
perforation  of  the  rectum  and  sigmoid  is  not  always  due  to  the  force 
used  in  the  introduction  of  the  foreign  body,  nor  to  rough  manipulation 
in  efforts  to  extract  it.  They  may  be  brought  about  by  peristaltic 
movement,  tenesmus,  and  straining  of  the  patient  himself.  In  this  case 
the  body  was  too  short  to  have  been  pushed  through  the  gut  by  the 
patient,  and  no  efforts  had  been  made  to  extract  it.  Where  such  a  body 
is  left  in  the  intestinal  canal  for  any  undue  length  of  time  it  will  cause 
inflammation  and  ulceration  by  pressure,  thus  weakening  the  intestinal 
wall  and  inviting  perforation;  it  may  then,  during  a  spasm  or  period 
of  tenesmus,  be  thrust  through  into  the  peritoneal  cavity  and  cause 
death. 

The  prognosis  in  these  cases  will  therefore  depend  upon  the  nature 
and  shape  of  the  body,  upon  its  size,  the  force  with  which  it  is  intro- 
duced, the  roughness  of  manipulation  in  the  efforts  to  vrithdraw  it,  and, 
finally,  upon  its  location,  whether  above  or  below  the  peritoneal  cul-de- 
sac.  Perforation  of  the  bladder  through  the  rectum  is  likely  to  end 
fatally  through  infection  of  the  bladder  and  its  progression  to  the 
kidne3's. 

If  none  of  these  complications  occur,  and  the  bodies  are  promptly 
removed  and  properly  treated,  the  prognosis  in  these  cases  is  generally 
good.  Their  dangers,  however,  should  never  be  underrated,  and  posi- 
tive opinions  should  not  be  given  until  all  risk  of  secondary  complica- 
tions has  passed,  especially  in  cases  in  which  the  foreign  body  is  in  or 
above  the  sigmoid  flexure.  [Velpeau  (Elements  of  Surg.  Path.,  1858, 
p.  42),  Dor  (Gaz.  med.  de  Paris,  1833,  p.  199),  Lane  (Brit.  Med.  Jour., 
1874),  and  Tillaux  (Gaz.  hop.,  1877,  p.  695).] 

Treatment. — The  ingenuity  exercised  in  the  introduction  of  foreign 
bodies  into  the  rectum  is  only  exceeded  by  that  necessary  for  their  re- 
moval. They  are  generally  introduced  with  the  conical  end  upward,  and 
thus  the  sphincter  is  gradually  dilated  until  the  object  slips  from  the 
grasp  and  the  muscle  contracts  behind  it.  Their  removal  must  be 
obversely,  with  the  large  end  first,  and  is  consequently  more  difficult. 
The  spasm  of  the  sphincter  consequent  upon  the  traumatism  increases 
the  difficulty  of  withdrawal. 

Where  the  body  is  of  a  soft  substance,  such  as  wood,  it  may  be 
grasped  by  a  forceps,  or  a  gimlet  or  screw  may  be  introduced  into 
it  to  assist  in  its  removal.     When,  however,  it  is  composed  of  glass. 


FOREIGN  BODIES  IN  THE  RECTUM  AND  SIGMOID  FLEXURE    909 

porcelain,  steel,  or  stone,  it  will  be  much  more  difficult  to  grasp  it,  and, 
moreover,  the  breaking  of  the  object  into  fragments  will  greatly  com- 
plicate affairs.  Too  great  pressure  or  too  much  manipulation  of  the 
body  in  order  to  grasp  it  may  cause  it  to  slip  beyond  reach  and  enter 
the  sigmoid  flexure.  If  the  upper  end  of  the  object  be  pointed,  such 
manipulation  may  cause  it  to  perforate  the  intestine  and  bring  on  fatal 
peritonitis.  Thus  one  must  avoid  pressing  too  firmly  upon  the  abdomen 
from  above  or  upon  the  object  below  in  these  manipulations. 

In  general,  it  will  be  necessary  to  auEesthetize  the  patient  and  dilate 
the  sphincter  before  any  attempt  at  removal  is  made.  The  parts  should 
first  be  irrigated  thoroughly  with  antiseptic  solutions  to  remove,  as  far 
as  possible,  causes  of  infection.  After  this  a  large  injection  of  oil  will 
facilitate  the  operation  by  lubricating  the  parts  and  causing  the  body 
to  slip  more  easily  through  the  constricted  points.  If  the  caliber  of  the 
anus  is  found  insufficient  for  the  removal  of  the  foreign  body,  it  will 
be  advisable  to  split  the  rectum  backward  to  the  coccyx  and  upward 
through  the  internal  sphincter.  By  this  procedure  abundant  room  will 
generally  be  afforded  for  the  removal  of  any  bod}^  which  has  originalh^ 
been  introduced  through  the  anus.  Sometimes  it  may  be  necessary  to 
excise  the  coccyx  before  the  body  can  be  removed.  Buffet  has  reported 
a  case  of  this  kind  (N'ormandie  med.,  1894). 

The  necessity  of  such  operations  is  brought  about  by  the  congestion, 
oedema,  and  swelling  following  the  introduction  of  the  objects;  other- 
wise a  body  which  passed  through  the  anus  going  in  could  be  forced 
through  it  on  withdrawal.  Wlien  the  lower  ends  of  these  bodies  are 
rough  and  serrated,  their  withdrawal  is  made  difficult  or  impossible, 
owing  to  the  fact  that  these  points  and  rough  ends  catch  in  the  mu- 
cous membrane  or  the  folds  of  the  rectum  and  arrest  their  passage  in 
the  outward  direction.  In  such  cases  the  operator  will  have  to  exercise 
his  ingenuity  to  cover  such  points  by  gauze  or  other  substance  in  order 
to  facilitate  their  withdrawal. 

The  classical  case  of  Marchettis  (Poulet,  loc.  cit.,  p.  260)  illustrates 
this.  A  boar's  tail,  with  the  bristles  cut  short  and  pointing  toward  the 
end,  was  introduced  into  the  rectum,  leaving  a  small  portion  of  the  end 
extending  through  the  anus.  Any  effort  to  pass  it,  or  at  withdrawal, 
only  sunk  the  bristles  more  deeply  into  the  mucous  membrane  and  held 
it  in  position.  Marchettis  ingeniously  selected  a  hollow  reed,  and,  after 
having  first  tied  a  string  to  the  end  of  the  tail  and  passed  it  through 
the  reed,  he  slipped  the  latter  upward  upon  the  boar's  tail,  thus  reversing 
the  direction  of  the  bristles  and  loosening  them  from  their  punctures 
in  the  mucous  membrane.  He  thus  removed  the  body  with  great  suc- 
cess, and  gave  immediate  relief  to  the  patient. 

When  the  body  is  composed  of  soft  metal,  such  as  hairpins,  wire, 


910  THE  ANUS,  RECTUM,  AXD   PELVIC  COLON 

safety-pins,  nails,  etc.,  they  may  be  cut  in  two  with  forceps  and  re- 
moved piecemeal. 

Lefort  has  suggested  that  when  the  body  is  hollow  it  might  be  filled 
with  plaster  of  Paris,  allowing  this  to  harden,  with  a  handle  of  some 
kind  in  its  center,  thus  affording  a  grip  by  which  it  can  be  removed. 
This  is  an  ingenious  method,  but  unfortunately  in  most  cases  the  open- 
ing into  such  bodies  is  upward,  and  the  filling  it  with  plaster  from  this 
direction  would  be  impossible  and  at  the  same  time  useless. 

The  application  of  an  obstetric  forceps  has  been  advised  by  some 
writers,  but  one  can  understand  how  difficult  it  would  be  to  apply  them 
to  a  large  body  in  the  rectum.  A  very  small  placental  forceps  might 
be  useful  in  removing  smooth,  round  bodies  which  it  is  difficult  to 
grasp. 

Where  the  object  is  of  glass,  china,  or  any  fragile  material,  great 
care  must  be  exercised  not  to  break  the  same  if  it  can  possibly  be 
avoided,  lest  the  fragments  should  cut  the  blood-vessels  and  cause  severe 
haemorrhage  or  puncture  the  peritonjeum.  Occasionally  it  must  be  done; 
it  is  well  under  such  circumstances  to  pack  a  layer  of  gauze  around  the 
foreign  body  between  it  and  the  rectal  wall  before  shattering  it,  in  order 
to  collect  as  many  of  the  small  pieces  as  possible,  and  to  protect  the 
rectal  wall  from  injury  by  the  fragments.  This  is  not  a  difficult  pro- 
ceeding; if  the  body  is  low  enough  down  to  be  grasped  and  broken,  it 
can  be  steadied  while  the  gauze  is  being  packed  around  it.  If  the  ob- 
stetric or  placental  forceps  is  used,  it  should  be  covered  with  gauze 
or  flannel  for  this  purpose. 

A  complication  has  arisen  in  some  cases,  in  which  a  body  with  an  open 
aperture  at  the  upper  end  has  been  introduced  into  the  rectum,  from 
the  fact  that  straining  and  tenesmus  have  caused  the  upper  segments 
of  the  bowel  to  prolapse  into  this  aperture,  and,  becoming  congested 
and  swollen,  thus  absolutely  obstructed  the  intestine. 

The  difficulty  here  is  not  only  in  the  removal  of  the  body,  but  in 
doing  so  without  injuring  the  prolapsed  gut.  If  the  bottom  can  be 
perforated  and  cocaine  or  extract  of  suprarenal  capsule  applied,  the 
congestion  may  be  so  reduced  that  the  prolapse  will  be  released,  and 
then  the  body  can  be  removed  without  much  injury  to  the  parts;  other- 
wise the  object  will  have  to  be  broken  and  the  injuries  repaired. 

Another  danger  with  regard  to  such  bodies  in  the  rectum  is  that  by 
too  vigorous  and  unwise  manipulation  they  may  be  pushed  upward  into 
the  sigmoid  flexure,  where  they  can  no  longer  be  felt  by  the  finger  or 
grasped  by  any  instrument  to  withdraw  them  from  below.  It  is  said 
that  these  bodies  are  carried  up  in  this  direction  and  beyond  reach 
by  the  retroperistaltic  action  of  the  intestine  described  by  O'Beirne. 
I  have  never  seen  anything  that  convinced  me  of  this  action.     Bodies 


FOREIGN  BODIES  IN  THE   RECTUM   AND   SIGMOID   FLEXURE     911 

which  have  trayeled  up-«'ard  in  tliis  way  haA'e  always  been  those  which 
had  sharp  edges  or  points  below,  so  that  when  the  motion  of  the  body 
or  intestine  took  place,  they  were  lifted  up  little  by  little,  exactly  in 
the  same  way  that  a  head  of  bearded  rye,  when  introduced  upside  down 
into  the  lower  end  of  a  hoy's  trousers,  will  crawl  up  to  his  shirt-collar 
as  he  walks  along.  The  retroperistaltic  action  is  not  necessary  to  ac- 
count for  the  movement  of  these  bodies;  it  is  simply  a  question  of 
mechanical  action,  which  is  found  in  numerous  instances  in  nature. 

Sometimes  where  the  foreign  body  has  come  from  above  and  has 
lodged  in  the  sigmoid  flexure,  the  introduction  of  a  long  sigmoidoscope 
to  establish  its  presence  and  to  determine  its  nature  may  straighten 
out  the  convolutions,  excite  an  active  peristalsis,  and  cause  the  body  to 
be  expelled  shortly  thereafter.  This  occurred  in  the  case  of  a  friend 
of  the  author's,  who  swallowed  his  false  teeth.  The  plate  was  not 
found  in  the  rectum  or  seen  in  the  sigmoid  at  the  time  of  examination, 
but  within  an  hour  afterward  it  was  protruded  at  the  anus  during  stool. 
If  the  body  can  be  seen  through  such  a  tube  it  may  be  located  at  the 
end  of  the  instrument,  grasped  with  an  alligator  forceps,  and  gently 
drawn  out  through  the  intestine.  If  the  pneumatic  proctoscope  is  used, 
the  dilatation  of  the  gut  will  allow  of  the  bod}''s  being  passed  along  with- 
out any  mutilation  of  the  parts. 

Always  after  the  removal  of  a  foreign  body  from  the  rectum  the 
organ  should  be  thoroughly  irrigated  and  washed  out  with  antiseptic 
solutions,  such  as  boric  acid  or  l-to-8^000  bichloride  of  mercury.  If 
the  bowels  have  not  been  moved  regularly,  a  cathartic  should  be  given 
at  once  to  relieve  them  of  any  accumulation  that  may  be  present.  But 
as  soon  as  this  has  been  accomplished,  some  opiate  or  sedative  should 
be  given  to  quiet  the  peristaltic  action,  and  thus  give  an  opportunity 
for  rest  and  the  subsidence  of  all  congestive  and  inflammatory  compli- 
cations. 

The  application  of  styptics  to  control  hsemorrhage  in  the  rectum 
has  been  productive  of  more  harm  than  good.  Irrigation  with  cold  or 
very  hot  water  and  pressure  by  packing  are  the  best  means  to  accom- 
plish this. 

Piemoval  ly  Cceliotomy. — ^Wlien  large  bodies  have  escaped,  or  have 
been  arrested  in  the  sigmoid  flexure,  much  manipulation  to  remove  them 
through  the  rectum  shotild  be  avoided.  The  dangers  of  rupturing  the 
gut  above  the  Juncture  of  the  sigmoid  and  rectum  are  always  present, 
and  if  the  foreign  body  has  produced  inflammation  of  the  parts,  these 
will  be  increased.  Under  such  circumstances  the  proper  and  rational 
proceeding  is  to  open  the  abdominal  cavity  at  once,  make  a  longitudinal 
incision  in  the  gut,  and  remove  the  foreign  body  through  this  aperture. 
If  the  gut  is  healthy  and  not  gangrenous,  it  should  be  closed  and  dropped 


912  THE   ANUS,  RECTUM,   AND   PELVIC   COLON 

back  into  the  abdominal  cavity;  otherwise  it  should  be  drawn  through 
the  abdominal  wound  until  all  the  diseased  area  is  outside,  and  then 
sutured  to  the  edges.  It  may  be  cut  otf,  or  if  it  resumes  its  normal 
condition  it  can  be  closed  and  restored  to  the  abdominal  cavity  at  a  later 
period.  The  incision  for  such  an  operation  should  always  be  made  at 
the  left  side  and  in  line  with  the  rectus  muscle,  inasmuch  as  the 
sigmoid  and  descending  colon  can  be  most  easily  reached  from  this 
point. 

When  the  foreign  body  has  been  located  in  the  intestine  it  should 
be  drawn  out  of  the  abdomen,  if  possible,  and  the  cavity  thoroughly 
packed  off  with  sterilized  gauze  before  the  gut  is  opened.  Sometimes, 
on  account  of  its  length,  it  is  impossible  to  draw  the  entire  body  out 
of  the  wound.  In  such  cases,  for  instance,  as  that  of  Pierra,  in  which 
the  piece  of  wood  was  9^  inches  long,  only  a  part  of  it  could  be  brought 
out  before  the  intestine  was  opened. 

Thorndike  (Boston  City  Hospital,  1882)  reports  the  case  of  a  man, 
forty-one  years  of  age,  who  had  been  in  the  habit  of  introducing  for- 
eign bodies,  such  as  bottles  and  jars,  into  his  rectum  for  the  relief  of 
the  retention  of  urine.  At  one  time,  not  having  any  of  the  objects 
which  he  was  in  the  habit  of  using,  and  finding  a  comparatively  round, 
smooth  stone  (weighing  about  3  pounds,  elliptical  in  shape,  and  smaller 
at  one  end  than  at  the  other),  greased  it,  and,  introducing  the  smaller 
end  into  his  anus,  sat  down  upon  it.  AVhile  he  was  thus  seated  the 
sphincter  gave  way,  and  the  stone  suddenly  shot  up  into  the  rec- 
tum. Efforts  were  made  by  surgeons  and  others  to  remove  it,  but 
the  more  it  was  manipulated  the  farther  it  receded  from  the  anus. 
A  small  boy  was  induced  to  pass  his  hand  and  arm  up  into  the  pa- 
tient's rectum,  but,  passing  it  the  whole  length,  could  not  reach  the 
stone. 

Thorndike  found  the  patient  forty-eight  hours  later  suffering  from 
tympanites,  pain,  high  temperature,  rapid  pulse,  and,  in  fact,  with  all 
the  symptoms  of  septic  peritonitis.  With  his  hand  in  the  rectum  he 
could  feel  the  foreign  body  in  the  abdominal  cavity,  but  could  not 
reach  it.  By  an  incision  at  the  outer  border  of  the  left  rectus  muscle 
the  peritoneal  cavity  was  opened,  and  the  stone  found  loose  among  the 
intestines.  The  aperture  through  which  the  stone  escaped  from  the  in- 
testine was  about  8  inches  above  the  anus,  and  was  not  gangrenous.  It 
was  closed  and  the  patient  recovered.  Now  it  is  perfectly  clear  that 
this  stone  was  thrust  through  the  intestinal  wall  by  the  efforts  to  re- 
move it.  Nature  would  never  exercise  retroperistaltic  force  enough  to 
rupture  her  own  organs  in  any  such  way  as  this. 

While  there  is  no  other  recourse  for  the  removal  of  foreign  bodies 
which  have  escaped  beyond  the  reach  of  instruments  and  the  hand  than 


FOREIGN  BODIES  IN  THE  RECTUM  AND  SIGMOID  FLEXURE    913 

laparo-enterotomy,  one  should  not  be  misled  by  the  literature  upon  this 
subject  as  to  the  favorable  prognosis  in  these  cases. 

Poulet  quotes  three  cases  in  which  the  operation  has  been  done,  and 
all  of  them  successfully.  Kelsey  quotes  the  same  three  cases.  Stuts- 
gaard,  Thorndike,  and  Realli  have  successfully  removed  large  foreign 
bodies  by  laparo-enterotomy,  but  all  the  cases  in  which  this  has  been 
tried  have  not  ended  so  favorably.  Thus  Stanton  (Brit.  Med.  Jour., 
1881,  vol.  i,  p.  848)  removed  a  wine-bottle  by  this  method,  and  the  opera- 
tion was  promptly  followed  by  death.  Hunter  (Trans,  and  Phys.  Soc, 
Bombay,  1860,  p.  24)  attempted  to  remove  the  horn  of  a  bullock,  which 
had  been  passed  into  the  rectum,  by  abdominal  section.  The  patient 
died  shortly  afterward. 

In  another  case,  in  which  a  glass  telegraph  insulator  was  introduced 
into  the  rectum  and  passed  up  into  the  sigmoid,  laparo-enterotomy  was 
performed  with  a  fatal  result  (Review  Medical  Quir.,  Buenos  Ayres, 
1883,  p.  125). 

Bryant  (Med.  Press  and  Circ,  London,  1825,  p.  228)  reports  a  case 
of  laparo-enterotomy  for  a  foreign  body,  after  which  the  patient  died. 

Gentilhomme  removed  a  foreign  body  from  the  rectum  by  inguinal 
enterotomy,  sutured  the  intestine,  and  dropped  it  back  into  the  ab- 
dominal cavity  with  a  successful  result. 

Trull  (Boston  Med.  and  Surg.  Jour.,  1870,  p.  3)  operated  upon  a 
patient  who  had  introduced  a  stone  into  his  rectum,  which  soon  per- 
forated the  rectal  wall  and  escaped  into  the  abdominal  cavity;  the 
foreign  body  was  removed  by  an  abdominal  incision,  the  rent  in  the 
intestinal  wall  through  which  it  had  escaped  was  sewed  up,  and  the 
patient  made  a  good  recovery.  (This  appears  to  be  the  same  case  re- 
ported by  Thorndike.)  The  facts  are  practically  the  same  in  all:  either 
the  foreign  body  has  escaped  upward  into  the  colon  or  sigmoid,  and, 
being  beyond  the  reach  of  the  surgeon,  it  has  been  necessary  to  remove 
it  by  abdominal  section,  or  the  wall  of  the  intestine  has  been  ruptured 
and  the  body  has  escaped  into  the  abdominal  cavity.  Happily  the  peri- 
tonaeum seems  wonderfully  tolerant  of  faecal  matter  for  a  brief  length 
of  time,  and  if  it  is  promptly  wiped  out  and  extravasation  and  suppura- 
tive products  prevented  from  reentering,  peritonitis  may  be  very  fre- 
quently avoided. 

One  interesting  case  of  spontaneous  exit  of  a  foreign  body  through 
the  abdominal  wall  is  worthy  of  mention.  Yergely  (Jour,  de  med.  de 
Bordeaux,  1884-'85,  p.  575)  reported  the  case  of  a  young  man  who  had 
introduced  into  his  rectum  a  penholder  19  centimeters  long.  He  suf- 
fered no  inconvenience  in  the  rectum  particularly,  and  consulted  no 
physician,  but  finally  began  to  have  pain  in  the  abdominal  wall  at  the 
juncture  of  the  hypochondriac  and  right  inguinal  region.  After  a  time 
58 


914  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

a  small,  hard  object  was  felt  in  this  region.  It  soon  penetrated  the 
abdominal  wall,  and  proved  to  be  the  penholder  which  had  thus  been 
spontaneously  expelled.  Whether  it  had  followed  the  course  of  the 
intestine  all  around  the  descending,  transverse,  and  ascending  portions 
of  the  colon,  or  whether  it  had  perforated  the  rectum  or  sigmoid  flexure 
over  toward  the  right  side,  and  penetrated  the  abdominal  wall  through 
this  route,  is  not  definitely  known. 


CHAPTEE    XXIII 

WOUNDS,   INJURIES,   AND  RUPTURE  OF  THE  RECTUM 

Wounds  and  Injuries. — The  anus  and  rectum,  owing  to  tlieir  pro- 
tected position  between  the  folds  of  the  buttocks  and  within  the  bones 
of  the  pelvis,  are  not  frequently  injured  through  external  agencies.  A 
sufficient  number  of  accidents,  however,  has  occurred  to  make  the 
subject  worthy  of  consideration.  Injuries  to  these  organs  may  result 
in  contused,  lacerated,  punctured,  or  incised  wounds.  The  contusions 
result  chiefly  from  pressure  of  the  foetal  head  during  prolonged  labor, 
pressure  from  ill-fitting  pessaries,  the  prolonged  retention  of  foreign 
bodies  in  the  rectum,  too  forcible  manipulation  in  stretching  the  sphinc- 
ter, falls  upon  the  buttocks,  and  pressure  from  pelvic  tumors. 

Lacerated  wounds  occur  from  the  introduction  of  foreign  bodies, 
divulsion  of  the  sphincter,  the  passage  of  coproliths  or  sharp  foreign 
bodies  in  the  stools,  such  as  fish-bones,  pins,  pieces  of  metal,  etc.,  the 
sitting  do^^Ti  or  falling  upon  rough,  sharp  objects.  Chamber-pots  have 
broken  while  the  patients  were  sitting  upon  them,  resulting  in  laceration 
and  severe  haemorrhage,  even  in  severing  the  external  sphincter,  and 
resulting  in  partial  incontinence.  Punctured  wounds  of  the  rectum  and 
anus  occur  chiefly  through  gunshot  and  bayonet  injuries,  but  occasion- 
ally through  other  accidents.  The  records  of  the  late  civil  war  in  the 
United  States  show  that  in  103  gunshot  injuries  of  the  rectum,  44,  or 
42.7  per  cent,  of  them  resulted  fatally.  In  the  Franco-Prussian  War 
there  occurred  31  wounds  of  the  rectum,  with  15  deaths.  In  one  man 
the  rectum  was  penetrated  by  the  sharp  stump  of  a  weed,  over  which  he 
squatted  down  for  the  purpose  of  stool;  the  point  entered  about  1  inch 
from  the  margin  of  the  anus,  and  penetrated  the  rectum  ^  an  inch  above 
the  internal  sphincter.  Such  wounds  may  also  occur  through  accidents 
in  passing  a  urethral  sound;  a  false  passage  is  made  and,  owing  to  the 
unhealthy  condition  of  the  sseptum,  the  instrument  penetrates  the 
rectum. 

Numerous  cases  of  perforating  wounds  of  the  rectum  have  been  re- 
ported through  patients  falling  upon  sharp  bodies  which  passed  through 
the  anus  without  injury  to  it,  and  punctured  the  wall  of  the  rectum 

915 


916  THE   ANUS,  RECTUM,  AND   PELVIC   COLON 

higher  up.  A  strange  coincidence  lies  in  the  fact  that  nearly  all  the 
cases  in  which  the  perforating  body  has  passed  through  the  anus  with- 
out injury  at  that  point  and  perforated  the  rectal  wall  above  the  in- 
ternal sphincter,  have  proved  fatal.  Among  the  most  frequent  sources 
of  this  kind  of  injury  is  the  improper  use  of  syringes  and  rectal  bougies. 
Xordmann  (Kelsey,  p.  463)  has  recorded  25  separate  injuries  to  the 
rectum  due  to  the  improper  use  of  syringe-tips  in  the  administration 
of  enemata;  Edwards  records  a  case  in  which  a  full  quart  of  soap  and 
water  was  injected  into  the  perianal  tissues  in  an  attempt  to  administer 
a  clyster.  In  this  case  the  tissue  sloughed,  the  rectum  was  practically 
dissected  out  from  its  attachments  to  the  muco-cutaneous  border,  and 
retracted  upward,  thus  leaving  a  large  cavity  for  the  accumulation  of 
faecal  material. 

Injuries  from  the  use  of  rectal  bougies  are  not  so  frequent  at  the 
present  day  owing  to  the  fact  that  stiff  instruments  are  very  seldom 
used  for  this  purpose.  Formerly,  when  the  old  conical,  hard,  stiff 
bougie  was  used,  such  wounds  were  not  at  all  infrequent.  Xumerous 
instances  have  been  reported  in  which  the  wall  was  perforated  and  the 
instrument  passed  either  into  the  cellular  tissue  around  the  rectum  or 
into  the  peritoneal  cavity,  thus  causing  death.  Three  instances  are 
known  by  the  author  in  which  the  use  of  the  Kelly  tube  resulted  in 
the  perforation  of  the  rectal  wall,  ffecal  extravasation,  peritonitis,  and 
death. 

Instruments  penetrating  the  rectum  may  occasion  more  than  one 
wound.  Burnier  (Eevue  med.  de  la  Suisse  Normandie,  1885,  vol.  v,  p. 
171)  reports  the  case  of  a  boy  who  fell  upon  a  flat  bar  of  iron,  which 
penetrated  the  anus,  perforating  the  peritoneum  at  6  centimeters  (21 
inches),  and  entered  the  rectum  again  at  8  centimeters  (3^\  inches) 
above. 

Wounds  of  the  rectum  in  operations  for  stone  by  perineal  section 
have  frequently  occurred,  and  they  may  be  inflicted  during  the  operation 
of  prostatectomy.  Wounds  of  the  rectum  and  sigmoid  during  opera- 
tions for  pelvic  tumors  or  vaginal  hysterectomy  are  not  at  all  rare;  it 
is  very  easy  to  catch  a  fold  of  the  gut  in  the  clamps  or  angeiotribe, 
and  thus  wound  it. 

Rupture  of  the  Rectum. — Fowler,  Xicaise,  and  Hatche  have  each 
reported  instances  in  which  the  rectum  has  been  ruptured  by  the  use 
of  the  colpeurynter  in  suprapubic  cystotomy.  White  and  ^lartin  state 
{op.  cit.,  p.  707)  that  this  accident  has  occurred  so  frequently  that  the 
large  majority  of  surgeons  no  longer  make  use  of  this  apparatus.  Drag- 
ging upon  the  organ  in  efforts  to  break  up  attachments  between  it  and 
pelvic  neoplasms  have  frequently  resulted  in  this  injury.  The  author 
has  reported  one  case  in  which  the  accident  occurred  through  the  pas- 


"WOUNDS,  INJURIES,  AND   RUPTURE   OF   THE   RECTUM         917 

sage  of  an  extra-uterine  fcetus  into  the  rectal  cayity.  Several  cases  have 
occurred  during  efforts  for  the  reduction  of  rectal  procidentia. 

In  the  chapter  upon  examinations  the  fatalities  supposed  to  have  re- 
sulted from  the  introduction  of  the  hand  into  the  rectum  have  been 
reviewed  at  some  length;  -^hile  in  none  of  these  cases  was  there  any  abso- 
lute rupture  of  the  entire  rectal  wall,  yet  one  can  not  doubt  but  that  this 
injury  may  occur  from  such  a  procedure  where  the  hand  is  large  and 
the  rectal  cavity  small  and  non-distensible. 

Prognosis. — The  gravity  of  wounds  and  injuries  to  these  organs  will 
depend  largely  upon  their  site  and  the  tissues  and  organs  involved. 
Where  the  injury  is  confined  to  the  anus  and  rectal  walls,  the  wotinds 
usually  heal  under  proper  antiseptic  precautions,  and  no  serious  results 
follow. 

Sims  (British  Med.  Jour.,  February  18,  1883)  claims  that  gunshot 
wounds  of  the  rectum,  although  involving  the  pelvis,  bladder,  and  peri- 
ngeum,  are  not  very  fatal.  Out  of  T  eases  occurring  at  Sedan,  all  recov- 
ered. The  records,  however,  of  our  civil  war  and  those  of  the  Franco- 
Prussian  War  do  not  bear  out  this  statement.  The  statistics  in  both 
of  these  cases  record  a  mortality  of  over  40  per  cent.  "  Pelvic  cellulitis 
and  septicsemia  from  infiltration,  diffuse  suppurations,  and  other  con- 
secjuences,  obstructions,  lesions,  and  secondary  bleeding  were  the  com- 
plications which  most  frequently  preceded  a  fatal  termination  in  this 
group  of  cases  "  (Medical  and  Surgical  Histor}-  of  the  AVar  of  the  Re- 
bellion, Surg.  Vol.). 

Where  the  bladder  is  involved  in  the  injury  and  the  wound  is  suffi- 
ciently large  to  admit  of  fEecal  extravasation  into  that  organ,  the  acci- 
dent should  be  considered  very  grave.  Fourteen  out  of  3-1  such  cases 
resulted  fatally. 

The  seriousness  of  any  injury  to  the  rectum  depends,  first,  upon 
its  height  and  extent;  second,  upon  the  form  of  the  body  causing  it, 
its  direction,  and  the  force  by  Avhich  it  is  made  to  penetrate:  and, 
finally,  upon  the  length  of  time  elapsing  between  the  injury  and  the 
observation  of  the  surgeon.  The  principal  factor  in  aU  these  injuries 
is  the  wounding  of  the  peritonaeum.  Septic  peritonitis  ordiuardy  de- 
velops within  twelve  to  fourteen  hours.  It  may  be  possible,  therefore, 
in  injuries  in  which  this  cavity  has  been  penetrated,  to  open  the  abdo- 
men, clean  it  out  thoroughly,  close  the  wound  in  the  gut,  and  thus 
prevent  the  development  of  septic  inflammation.  In  all  such  cases 
there  is  a  certain  amount  of  localized  traumatic  peritonitis,  but  this 
condition  is  not  necessarily  fatal.  A"an  Hook  has  collected  58  cases  of 
injury  to  the  rectum,  of  which  28  were  complicated  by  woimds  of  the 
peritongeum  (]^Ionthly  Jour,  of  ]\Ied.  and  Surgery,  June,  1896).  Of  the 
26  cases  in  which  there  was  perforation  of  the  peritonaeum,  death  fol- 


91S  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

lowed  in  20,  and  recovery  in  6,  cases.  In  the  large  majority  of  these 
no  operation  was  done  until  long  after  the  period  for  the  development 
of  septic  peritonitis  had  passed. 

In  30  cases  in  which  the  peritonaeum  was  not  injured,  all  recovered. 
The  point  at  which  the  peritonaeum  had  been  penetrated  varied  from  5 
to  25  centimeters  (from  2  to  9|^  inches).  In  the  case  of  Lambotte,  the 
foreign  body  penetrated  the  wall  of  the  rectum,  and  afterward  entered 
the  sigmoid  flexure.  Instances  of  injury  to  the  omentum  (Kurella),  the 
jejunum  and  liver  (Poulton),  the  psoas  muscle  (Heath),  the  mesentery 
and  ileum  (Watson),  the  diaphragm  and  mediastinum  (Chattergee),  have 
been  reported,  and  one  even  in  which  the  puncturing  body  passed  up- 
ward to  the  flexure  of  the  neck  (Woodbury).  Hemorrhage  from  such 
wounds  is  usually  checked  by  pressure  of  the  wounding  object,  if  the 
latter  is  not  withdrawm,  or,  owing  to  the  lacerated  character  of  the 
wound,  ceases  itself  before  the  surgeon  reaches  the  case.  There  is  no 
record  of  a  case  of  serious  or  fatal  haemorrhage  from  such  accidents. 
Infection  of  the  wound  is,  of  course,  likeh'  to  occur  at  all  times;  this, 
however,  can  be  prevented,  or  at  least  controlled,  by  free  drainage  and 
proper  antiseptic  treatment.  Abscesses,  fistulas,  and  ulcerations  may 
result  from  such  wounds,  but  they  can  not  be  considered  as  serious 
results. 

Symptoms. — It  requires  no  detailed  symptomatology  to  recognize  an 
injury  or  wound  of  the  rectum,  as  the  history,  the  appearance  of  the 
parts,  the  loss  of  blood,  pain,  and  shock  will  clearly  indicate  what  has 
happened.  Symptoms  which  indicate  the  involvement  of  other  parts, 
however,  especially  the  peritonaeum,  are  of  the  greatest  importance.  In 
the  latter  case  they  are  those  of  immediate  traumatism,  shock,  haemor- 
rhage, and  pain.  All  of  these  differ  greatly  in  individuals.  In  several 
of  the  cases  reported  by  Van  Hook,  in  which  the  peritoneum  was  pene- 
trated, pain  was  almost  entirely  absent.  In  some  the  haemorrhage  was 
exhausting,  while  in  others  there  seemed  to  be  none  at  all.  Shock  is 
a  very  variable  quantity;  some  patients  completely  collapse  and  become 
unconscious,  while  others  do  not  show  any  symptoms  of  it.  In  the 
case  reported  by  Heath,  a  boy  of  eighteen  walked  over  a  mile  to  the 
doctor's  office  after  a  penetrating  wound  of  the  rectum  involving  the 
peritongeum;  he  died  of  peritonitis  a  few  hours  afterward.  The  absence 
of  external  evidences  of  hemorrhage  may  be  very  deceiving.  "WTiile 
there  may  be  no  blood  discharged,  the  peritonaeum  and  the  upper  cavity 
of  the  rectum  may  be  filled  with  blood.  Tympanites  and  abdominal 
pain  may  occur  immediately  after  the  accident  or  they  may  be  delayed 
for  twenty-four  hours,  being  preceded  by  a  chill,  and  followed  by  all 
the  symptoms  of  septic  peritonitis;  meteorism  will  develop,  and  an  anx- 
ious expression  of  the  face,  vomiting,  hiccough,  and  collapse  compose 


WOUNDS,  INJURIES,  AND  RUPTURE  OF  THE  RECTUM        919 

the  final  picture  in  the  case.  Death  is  generally  quite  rapid,  occurring 
within  the  first  seventy-two  hours.  In  two  cases  reported  by  Quenu  it 
was  delayed  until  the  eighth  day,  and  in  one  (Xeal)  it  did  not  occur 
until  the  second  month. 

Quenu  and  "Watson  distinguish  between  the  deaths  due  to  peritoneal 
septicaemia  and  peritonitis,  and  claim  that  the  former  is  more  frequently 
the  cause  of  death  than  the  latter.  Watson  has  shown  that  a  wound 
may  penetrate  the  mucous  wall  of  the  intestine  without  involving  the 
peritoneal  cavity,  and  yet  at  the  same  time  peritonitis  may  follow.  Pain 
in  the  region  of  the  pubis,  dysuria,  the  presence  of  urine  in  the  rectum 
or  of  blood  and  faces  in  the  urine,  will  indicate  the  involvement  of  the 
bladder  in  these  injuries.  Sometimes  there  is  complete  retention  of  the 
urine,  and  the  patient  must  be  catheterized.  In  such  cases  one  may  find 
fgecal  material  and  blood  in  the  urine,  or  he  may  find  no  urine  in  the 
bladder  at  all,  it  having  escaped  through  the  bladder  into  the  rectum 
or  into  the  peritoneal  cavity. 

Aside  from  the  subjective  symptoms,  examination  of  the  organ  by 
the  finger  and  instruments  will  indicate  more  clearly  than  anything  else 
the  size  and  extent  of  the  injury.  Where  the  bladder  is  perforated,  one 
may  usually  reach  the  wound  with  the  finger,  or  see  it  at  least  through 
the  proctoscope.  We  should  not  be  deceived,  however,  by  the  fact  that 
there  is  no  leakage  of  urine  or  fseces  immediately  after  a  puncture  or 
gunshot  wound  involving  the  bladder  and  rectum.  The  congestion  and 
oedema  following  an  injury  of  this  kind  may  entirely  close  the  tract  of 
the  missile  for  the  time  being,  but  in  the  course  of  a  few  days  this 
reopens  through  subsidence  of  the  cedema  or  through  sloughing  of  the 
tissue  around  the  wound.  In  gunshot  wounds  especially  there  is  a  trau- 
matism which  radiates  in  all  directions  and  frequently  causes  gangrene 
around  the  tracts  some  days  after  the  injury;  thus,  while  there  may 
apparently  be  no  communication  between  the  two  organs  at  the  first 
examination,  it  is  altogether  possible  that  a  very  wide  one  may  develop 
at  a  later  date.  A  guarded  prognosis  is  therefore  necessary  in  such 
cases.  Sometimes  in  perforation  of  the  peritoneal  cavity  one  may  also 
be  able  to  determine  the  condition  with  the  finger;  &s  a  rule,  however, 
such  perforations  are  too  high  to  be  so  reached.  The  rectal  tube  or 
speculum  should  always  be  employed  to  examine  these  wounds.  By  the 
pneumatic  endoscope  or  the  ordinary  Kelly  tube  (with  the  patient  in 
the  knee-chest  posture)  one  may  be  able  in  the  majority  of  cases  to 
see  the  whole  field,  and  sometimes  pack  the  wound  so  as  to  avoid  further 
fffical  extravasation;  in  a  case  of  rupture  of  the  rectum  through  the 
passage  of  an  extra-uterine  foetus,  it  was  possible  to  control  the  hemor- 
rhage" and  pack  the  foetal  sac  in  this  way.  In  a  case  of  a  perforating 
wound  of  the  bladder  the  urine  could  be  seen  to  trickle  into  the  rectum. 


920  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

The  rapid  escape  of  air  from  the  rectum,  and  inability  to  inflate  this 
organ  after  a  suspected  perforation  of  the  peritonaeum,  would  be  indica- 
tive that  such  had  taken  place,  even  if  the  point  of  injury  could  not 
be  seen. 

Treatment. — The  treatment  of  the  rectal  wounds  and  injuries  may  be 
summed  up  in  the  brief  words  drainage  and  disinfection.  Where  these 
are  properly  carried  out  little  trouble  is  to  be  anticipated  from  minor 
wounds  or  injuries  confined  to  the  anus  and  rectum.  Hemorrhage 
should  be  controlled  according  to  the  surgical  principles  described  in  the 
chapter  upon  foreign  bodies.  The  rectum,  however,  should  always  be 
thoroughly  irrigated  with  hot  antiseptic  solution  before  it  is  packed, 
except  when  the  peritoneal  cavity  is  penetrated. 

If  fistulas,  abscesses,  or  ulceration  occur,  they  should  be  treated 
according  to  the  methods  heretofore  laid  down.  Perforations  of  the 
bladder  through  rectal  wounds  often  heal  spontaneously,  and  therefore 
in  those  cases  in  which  there  is  no  peritoneal  involvement  early  opera- 
tive interference  is  not  advisable.  The  bladder  ma}^  be  drained  by  a 
soft-rubber  catheter  and  the  rectum  kept  as  free  from  fecal  material 
as  possible  by  daily  cold-water  enemata,  and  if  after  due  time  the 
condition  develops  into  a  recto-vesical  or  reeto-urethral  fistula,  it  should 
be  treated  after  the  methods  heretofore  described. 

The  treatment  of  rectal  injuries  involving  the  peritoneum  is  of  the 
greatest  importance.  ^Yherever  there  is  any  reason  to  believe  that  the 
peritoneal  cavity  has  been  opened  through  a  wound  in  the  rectum  an 
exploratory  laparotomy  should  be  done  at  once,  and  the  site,  course,  and 
extent  of  the  injuries  determined.  In  doing  this  one  should  not  waste 
any  time  in  the  removal  of  the  patient,  but  should  operate  immediately 
without  any  undue  movement,  so  as  to  disturb  the  parts  as  little  as  pos- 
sible. If  there  should  be  much  extravasation  of  blood  and  fecal  material 
into  the  peritoneal  cavity  it  should  be  washed  out  thoroughly  with  large 
douches  of  normal  saline  solution.  If,  however,  there  is  only  a  very 
slight  escape,  it  is  better  to  wipe  the  parts  off  gently  with  pledgets  soaked 
in  mild  bichloride  solution.  It  is  better  to  clean  out  Douglas's  cul-de-sac 
by  this  method  than  by  general  irrigation,  for  by  the  latter  one  may 
distribute  throughout  the  cavity  septic  germs  which  were  originally  con- 
fined to  the  pelvic  space.  If  septic  peritonitis  has  begun,  Quenu  ad- 
vises prolonged  lavage  with  artificial  serum  at  40  degrees  centigrade, 
but  normal  saline  solution  is  quite  as  effectual. 

Wliere  the  wound  in  the  intestine  is  within  reach,  it  may  be  sutured 
and  dropped  back  into  the  abdominal  cavity,  or  it  may  be  brought  up 
and  attached  to  the  edges  of  the  abdominal  incision,  thus  forming  an 
artificial  anus.  If  the  wound,  however,  is  low  do^^Ti  in  the  pouch  of 
Douglas,  one  may  find  great  diflficulty  in  carrying  out  either  of  these 


WOUNDS,  INJURIES,  AND  RUPTURE  OF  THE  RECTUM        921 

methods.  A  colpeurynter  introduced  into  the  rectiun  will  lift  the  parts 
up  in  the  pelvis  to  a  certain  extent,  and  hring  them  within  easier  reach. 
One  need  not  mention  the  advantages  of  the  Trendelenburg  posture  in 
performing  such  operations;  the  patient  should  not  be  thrown  into  this 
position,  however,  until  after  the  pelvic  cavity  and  Douglas's  cul-de-sac 
have  been  thoroughly  cleaned  out. 

Where  the  opening  into  the  gut  can  not  be  closed  by  sutures,  and 
even  in  all  cases  where  it  has  been  closed,  it  is  advisable  to  pass  a  gauze 
wick  down  to  the  site  and  bring  it  out  through  the  lower  end  of  the  ab- 
dominal wound;  it  is  not  safe  to  close  this  up  without  drainage  in  any 
case  in  which  there  has  been  a  communication  between  the  intestine  and 
peritoneal  cavity. 

The  results  of  laparotomy  in  these  cases  are  very  encouraging.  In 
6  cases  in  which  the  operation  was  done,  4  recovered  and  2  died,  giving 
a  mortality  of  33^-  per  cent.  Of  29  cases  not  operated  upon,  5  recovered 
and  24  died — a  mortality  of  82  per  cent.  It  is  altogether  probable 
that  the  mortality  in  the  6  cases  would  have  been  still  less  had  the 
patients  been  operated  upon  before  the  time  for  the  development  of 
septic  peritonitis.  In  the  fatal  cases,  one  was  done  sixteen,  and  the 
other  more  than  twenty,  hours  after  the  injury. 

The  treatment  of  rupture  of  the  rectum  should  be  immediate  lapa- 
rotomy and  suture  of  the  wound.  If  it  has  occurred  during  the  manipu- 
lation of  a  prolapsed  gut,  amputation  above  the  point  of  the  rupture 
may  be  done,  and  laparotomy  thus  be  avoided.  It  is  not  safe,  however, 
to  attempt  to  close  these  wounds  by  suture  from  the  mucous  side.  In 
such  cases,  moreover,  laparotomy  and  dragging  upon  the  gut  from 
above  will  facilitate  the  reduction  of  the  prolapse,  and  in  all  probability 
one  will  be  able  to  close  the  wound  without  any  escape  of  fgecal  material 
into  the  peritoneal  cavity.  Under  such  circumstances  it  will  be  per- 
fectly proper,  after  having  sutured  the  intestinal  wound,  to  close  up 
the  abdominal  cavity  without  drainage. 


CHAPTER   XXIV 

NERVOUS  OR  HYSTERICAL  RECTU3I~INSANE  RECTUM— NEU- 
RALGIA OF  THE  RECTUM— OBSCURE  DISEASES  OF  THE 
RECTUM 

Undek  one  or  the  other  of  the  above  titles  a  large  variety  of  affec- 
tions of  the  rectum  have  been  described.  Curling  first  took  up  this 
subject  and  divided  these  cases  into  three  classes — the  "  irritable  rectum," 
"  neuralgia,"  and  "  morhid  sensibility  of  the  rectum." 

In  the  first  class  he  included  all  those  cases  in  which  the  rectum  is 
more  sensitive  to  nerve  influences,  and  reacts  abnormally  to  reflex  irri- 
tations. In  tlie  second  class  he  placed  all  those  cases  in  which  neuralgic 
pains  occur  about  the  lower  end  of  the  bowel  without  any  discoverable 
organic  lesion  in  the  rectum  itself.  In  the  third  class  he  included  those 
cases  in  which  there  is  a  true  hyperesthesia  associated  with  hypertrophy 
and  spasm  of  the  voluntary  muscles.  He  stated  that  in  the  majority  of 
such  cases  a  pathological  condition  exists  to  account  for  the  symptoms, 
under  which  circumstances  one  can  not  properly  class  them  under  the 
neuroses. 

Hysteria  and  neuralgia  are  two  very  vague  terms.  They  are  ordi- 
narily understood  by  practitioners  to  mean  a  condition  of  the  nerves 
or  the  nervous  system  to  account  for  which  there  is  no  pathological 
lesion  discoverable.  They  are  both  used  as  mantles  to  cover  up  our 
ignorance  in  many  instances,  and  when  hysterical  women  and  neuralgic 
rectums  are  mentioned,  it  is  generally  in  connection  with  cases  in  which 
there  has  been  a  failure  to  make  a  diagnosis. 

Neuralgias  are  always  the  expression  of  nerve  irritation,  either 
mechanical  or  pathological.  Whether  that  irritation  is  central  or 
peripheral  it  is  sometimes  impossible  to  state,  but  it  is  not  likely  that 
any  peripheral  nerve  persistently  or  periodically  produces  pain  unless 
there  is  some  excitation  of  the  sensory  fibers.  That  patients  sometimes 
overestimate  their  pain,  and  complain  more  of  sensitive  areas  at  different 
portions  of  the  body  than  the  pains  justify,  may  be  conceded;  but  in 
these  cases  there  is  always  a  disease  of  the  mind  or  of  the  general  nerv- 
ous system  which  renders  the  patient  incapable  of  bearing  pain.  In  other 
words,  all  pains  have  a  mechanical,  chemical,  or  pathological  cavise. 
923 


NERVOUS  OR  HYSTERICAL  RECTUM  923 

The  condition  ordinarily  described  as  hysteria  has  of  late  years  ob- 
.tained  much  greater  respect  among  physicians.  Formerly  a  woman 
who  fainted  or  cried  without  any  commensurate  provocation  was  con- 
sidered hysterical,  and  little  patience  was  had  with  her.  The  large 
majority  of  these  patients  have  been  found,  after  making  the  rounds 
of  different  specialists,  to  have  some  disease  of  the  ovaries,  uterus,  or 
other  organs  which  accounted  for  their  symptoms;  in  most  of  the  cases 
termed  nervous  or  hysterical  rectum,  if  one  searches  long  and  carefully 
enough,  he  will  find  some  local  or  reflex  cause  for  the  symptoms  exhibited. 

In  a  discussion  of  this  subject  before  the  American  Medical  Asso- 
ciation in  1888,  William  Goodell  stated  that  few  muscles  of  the  body 
are  exempt  from  attacks  of  hysteria,  and  that  the  circular  ones  are 
the  most  liable  of  all  to  be  so  attacked.  He  stated  that  "  in  many 
cases  the  mind  is  sane,  the  organic  body  is  sound,  the  individual  as  a 
whole  is  above  reproach,  and  yet  these  muscles  will  behave  as  if  bereft 
of  reason."  In  most  of  the  cases  so  affected,  according  to  this  author, 
one  will  find  symj)toms  of  nervous  prostration,  backaches,  and  ner- 
vousness, but  the  chief  symptom  is  referred  to  the  rectum.  So  intense 
is  this  symptom  that  it  masks  all  the  other  phenomena,  and  leads  one 
to  believe  that  he  is  dealing  with  some  marked  pathological  lesion  of 
the  organ. 

In  some  the  symptoms  closely  resemble  those  of  anal  fissure,  as  there 
is  great  pain  during  or  after  defecation;  in  others,  the  pain  is  higher 
up  than  the  sphincter  muscles,  and  there  is  a  periodicity  in  its  character 
which  is  probably  due  to  the  accumulation  of  fffices  in  the  rectum;  and 
in  others  still  there  is  a  throbbing,  pulsating  pain  that  occurs  before 
and  during  defecation,  but  disappears  after  the  bowels  have  been  emp- 
tied; this  may  be  more  intense  at  one  portion  of  the  rectum  than  at 
another,  as  in  those  cases  simulating  coccygodynia.  Aside  from  these 
cases  associated  with  actual  pain,  there  are  others  described  by  Goodell 
in  which  the  sphincter  muscle  is  persistently  and  powerfully  contracted 
without  any  cause  to  account  for  it. 

The  movement  of  the  bowels  is  not  associated  with  any  pain,  but 
requires  either  artificial  assistance  or  an  enema  before  it  can  be  accom- 
plished. In  these  cases  defecation  is  sometimes  followed  by  great  ex- 
haustion, whether  the  stool  is  fluid  or  solid.  In  other  cases  the  rectum 
is  so  sensitive  and  irritable  that  the  least  pressure  either  from  the  faeces 
low  down  within  it  or  the  introduction  of  the  syringe  will  bring  on 
spasm  and  actual  agony. 

The  least  excitement  from  social,  business,  or  other  causes  will  some- 
times bring  on  either  a  relaxation  of  the  sphincters  and  inability  to 
control  the  movements  of  the  bowels  or  a  spasm  of  those  muscles  which 
unfits  the  patient  for  society  or  affairs. 


924  THE  AXUS,  RECTUM,  AND   PELVIC  COLON 

Mathews  practically  denies  the  existence  of  any  such  symptoms 
without  a  commensurate  pathological  cause.  "When  Goodell  wrote  the 
article  referred  to,  his  methods  and  means  of  rectal  examination  were 
crude  and  unsatisfactory;  nevertheless,  they  were  as  good  as  any  others 
at  that  time,  and  it  is  improbable  that  he  overlooked  or  failed  to  ob- 
serve the  gross  pathological  lesions  which  are  claimed  by  Mathews 
to  account  for  all  these  conditions.  At  that  time  these  were  recognized 
as  well  as  the  reflex  influences  produced  by  diseases  of  the  bladder, 
uterus,  ovaries,  and  other  organs,  just  as  they  are  to-day;  but  after  all 
these  conditions  have  been  accounted  for,  there  still  exist  a  certain 
number  in  which  it  is  impossible  to  find  a  pathological  cause  for  the 
irregular  behavior  of  the  muscles.  The  author  knows  a  surgeon,  and 
has  examined  him  carefully  and  in  vain  to  find  any  abnormal  condition 
in  his  rectum,  who  before  he  enters  the  operating-room  must  invariably 
retire  to  the  toilet  to  have  a  movement  of  the  bowels,  notwithstanding 
he  has  already  had  his  regular  passage  for  the  day. 

Goodell  quoted  an  interesting  case  of  a  woman  whose  bowels  never 
gave  her  any  trouble  whatever  so  long  as  she  remained  at  home  and  in 
indoor  dress,  but  as  soon  as  she  put  on  her  hat  to  go  out,  a  painful  tenes- 
mus with  repeated  stools  began,  and  did  not  cease  until  she  took  off 
her  hat  and  resumed  her  household  duties.  Many  such  eccentric  in- 
stances can  be  mentioned,  and  are  only  explicable  through  some  ab- 
normal condition  of  the  nervous  system. 

In  those  cases  in  which  there  is  actual  pain  in  or  about  the  rectum 
associated  with  or  following  the  stool,  it  is  possible  ordinarily  to  find 
some  pathological  change  to  account  for  the  symptoms.  A  fissure, 
whether  active  or  healed,  a  small  ulcer  just  within  the  spnincter,  a 
hypertrophied  papilla  which  prolapses  and  is  caught  in  the  grasp  of  the 
sphincter,  a  small  polypus,  or  an  inflamed  hemorrhoid,  may  any  of  them 
produce  the  symptoms  described  as  obscure  diseases  or  hysteria  of  the 
rectum. 

A  small  ffpcal  concretion  or  foreign  body  lodged  in  one  of  the  crypts 
and  out  of  sight  may  keep  up  an  irritation  or  neuralgia  for  an  indefinite 
period;  in  a  case  of  this  kind  in  the  author's  experience  the  patient 
suffered  for  from  eighteen  to  twenty-four  hours  after  stool,  and  3'et 
many  examinations  by  a  noted  specialist  in  rectal  diseases  revealed 
nothing  whatever  to  account  for  the  symptoms;  the  rectum  and  crypts 
were  searched  carefully,  but  nothing  was  found  except  a  small  indurated 
ridge,  apparently  the  seat  of  an  old  fissure  which  had  healed.  It  was 
a  case  in  which  the  nerve-ends  had  become  caught  in  the  cicatrix,  and 
this  caused  a  neuritis.  In  another  case  a  similar  conclusion  was  about 
reached  when,  upon  withdrawing  the  speculum,  a  minute  drop  of  pus 
coming  from  just  above  the  muco-cutaneous  margin  was  observed.    At 


NERVOUS   OR   HYSTERICAL   RECTUM  925 

a  second  examination  a  very  fine  probe  was  introduced  into  one  of  the 
crypts  of  Morgagni,  and  a  small  burrowing  tract  extending  down  about 
^  an  inch  was  found.  The  moment  the  probe  entered  into  this  tract 
the  patient  shrieked  with  pain,  and  stated  that  it  was  the  same  kind  of 
suffering  she  had  every  time  she  went  to  stool.  The  little  crypt  was 
slit  up  and  the  sphincter  muscle  incised  under  the  influence  of  cocaine, 
and  within  ten  days'  time  she  was  entirely  well  of  a  condition  which 
had  lasted  for  months. 

]\Iany  of  these  cases  occur  in  young  women  who  have  not  been  taught 
the  importance  of  regularity  in  the  action  of  their  bowels,  and  conse- 
quently they  have  allowed  themselves  to  become  constipated  at  times, 
and  then,  by  the  use  of  cathartics  and  enemas,  have  brought  on  drastic 
movements,  forcing  large  fgecal  masses  through  the  sphincter  and  set- 
ting up  an  irritation  in  the  rectal  mucous  membrane.  The  pressure  of 
the  fgecal  mass  during  the  periods  of  constipation  produces  irritability 
of  the  lower  end  of  the  rectum,  h3^ertrophy  and  spasm  of  the  sphincter, 
and  congestion  of  the  blood-vessels  of  this  region.  Along  with  these 
changes  there  is  an  increase  in  the  fibrous  elements,  and  this  constricts 
the  nerve-ends,  thus  producing  neuralgias.  Allingham  believes  that 
this  congestion  accounts  for  a  large  number  of  the  cases  of  so-called 
nervous  rectum.  It  is  not  necessary  to  describe  here  the  influence  of 
ulcers  of  the  rectum  and  neoplasms,  such  as  pol}^i,  adenomata,  and 
papilloma,  in  producing  rectal  pain,  but  attention  should  be  directed 
to  a  condition  described  by  Ball,  Allingham,  and  Mathews,  in  which 
a  small  congested  or  irritated  spot  well  above  the  sphincteric  region 
causes  a  tenesmus  and  bearing-doAvn  sensation  in  the  organ.  The  slight- 
est abrasion  of  the  epithelium,  the  lodgment  of  small  foreign  bodies  or 
hard  fgecal  masses  in  diverticuli  of  the  rectum,  or  a  follicular .  inflam- 
mation, may  bring  on  symptoms  which  are  referred  to  the  anus,  owing 
to  the  fact  that  while  the  afferent  nerves  supply  the  upper  portion  of 
the  rectum  and  sigmoid  flexure  very  freely,  the  efferent  are  largely  dis- 
tributed to  the  lower  end  and  the  voluntary  muscles  of  the  organ.  Thus 
the  pains  may  be  far  removed  from  the  site  of  causative  lesion. 

Reflex  Irritations. — The  intimate  association  between  the  rectum  and 
the  genito-urinary  organs,  both  in  the  male  and  in  the  female,  will  ac- 
count for  many  reflex  symptoms  between  the  two.  It  is  well  known  to 
all  surgeons  how  diseases  of  the  rectum,  such  as  fissure,  fistula,  and 
ulceration,  may  simulate  uterine  or  urethral  diseases,  and  how  a  stricture 
in  the  deep  urethra  may  find  its  most  prominent  expression  in  neuralgia 
and  bearing-down  pains  in  the  rectum.  Prolapsed  ovaries,  subinvoluted 
uteri,  stone  in  the  bladder,  inflanmiations  of  the  seminal  vesicles,  all 
frequently  cause  rectal  symptoms  when  there  is  no  disease  of  this  organ 
at  all.    It  is  quite  necessary,  therefore,  that  the  rectal  surgeon  shall  be 


926  THE  ANUS,  RECTUM,   AND  PELVIC  COLON 

thoroughly  posted  in  regard  to  diseases  of  this  kind,  and  capable  of 
diagnosing  any  such  disorders.  Where  no  organic  lesion  can  be  found 
to  account  for  the  symptoms  in  the  rectum  a  systematic  examination 
of  the  other  organs  of  the  pelvis  should  always  be  made. 

Nerve  Affections. — Frequently,  however,  nothing  will  be  found  in 
any  of  these  organs  to  account  for  the  neuralgic  pains  or  irregular  symp- 
toms that  occur  in  the  rectum.  In  such  cases  one  must  have  recourse 
to  the  study  of  the  nervous  system,  especially  the  spinal  cord.  Spasm 
and  pain  about  the  rectum  are  not  infrequent  symptoms  in  the  begin- 
ning of  locomotor  ataxia;  in  many  of  these  cases  the  pains  occur  in  the 
rectum  before  they  do  in  the  legs  and  sciatic  regions. 

Allingham  states  that  in  the  beginning  of  mania  one  often  observes 
the  patient  has  severe  pains  in  the  rectum  without  any  pathological  con- 
dition to  account  for  the  same.  Reference  has  been  made  to  the  fact 
that  accumulation  of  faeces  in  the  rectum  or  sigmoid  flexure  may,  by 
its  irritation  or  the  auto-intoxication  produced  thereby,  bring  about 
symptoms  of  insanity  with  delusions,  which  are  relieved  when  the  iin- 
paction  has  been  removed.  One  must  therefore  be  careful  to  distinguish 
between  the  cause  and  effect  in  such  cases. 

Rheumatism  and  Gout. — In  the  chapter  upon  pruritus  attention  was 
called  to  the  influence  of  gout  or  rheumatism  in  producing  rectal  symp- 
toms; not  infrequently  the  muscles  and  perirectal  tissues  are  the  seat 
of  gouty  or  rheumatic  inflammations.  The  writer  has  quite  frequently 
operated  for  hgemorrhoids  upon  patients  who  suffered  with  severe  aching 
pain  around  the  anus,  expecting  the  operation  and  stretching  of  the 
sphincter  would  bring  radical  relief;  but  after  a  few  days  all  the  old 
pains  returned.  In  such  patients  the  administration  of  large  doses  of 
salicylates  with  alkaline  diuretics  have  invariably  given  relief,  whereas 
the  operation  had  done  no  good  in  this  direction.  In  a  number  of  such 
cases  operation  has  been  deferred  until  the  effect  of  therapeusis  was 
tested,  and  it  has  been  gratifying  at  times  to  find  that  the  medication 
entirely  relieved  the  sionptoms  without  a  resort  to  operative  interfer- 
ence. The  fact  that  full  doses  of  colchicum  sometimes  relieves  these 
symptoms  lends  color  to  the  theory  that  gout  may  occasionally  cause 
them. 

Insensitive  Rectum. — This  consists  in  a  decrease  of  the  normal  sensi- 
bility of  the  rectum.  The  patient's  bowels  will  be  perfectly  regular  for 
Aveeks  at  a  time,  then,  after  a  period  of  nervous  strain  or  excitement, 
either  from  social  or  business  affairs^,  there  will  come  on  a  diarrhoea 
with  involuntary  passages  of  fseces  lasting  for  several  days.  The  patient 
will  have  no  warning  or  sensation  of  such  an  impending  crisis  until  the 
actual  escape  of  the  faecal  material.  Under  such  circumstances  they 
become  hypochondriacal  and  depressed,  unfit  for  society,  and  at  times 


NERVOUS  OR  HYSTERICAL  RECTUM  927 

utterly  unable  to  keep  themselves  clean.  In  one  patient  this  condition 
continued  for  three  years;  it  first  developed  after  a  combined  operation 
for  haemorrhoids  and  appendicitis,  the  hasmorrhoidal  operation  having 
been  done  one  week  later  than  the  appendectomy;  for  a  time  it  was 
thought  it  was  due  to  overstretching  or  to  some  inflammatory  condition 
around  the  anus,  but  prolonged  observation  and  many  examinations  have 
failed  to  find  any  lesion  or  lack  of  sphincteric  power  to  account  for  the 
symptoms;  sensation  in  the  mucous  membrane,  however,  is  below  par. 
Had  a  Whitehead  operation  been  done  in  this  case,  one  would  have  said 
that  the  tactile  or  sensitive  area  of  the  rectum  had  been  removed;  inas- 
much as  a  simple  clamp-and-cautery  operation  involving  only  a  very 
small  portion  of  the  circumference  of  the  rectum  was  done,  no  such 
explanation  can  be  given.  This  patient  is  of  a  very  excitable  tempera- 
ment, suffers  greatly  from  insomnia,  and  has  a  small  abdominal  aneu- 
rism. The  faecal  passages  occur  when  she  is  Just  dropping  off  to  sleep 
or  when  she  is  busily  engaged  in  her  social  or  household  duties.  It 
would  appear,  therefore,  that  the  cause  lies  in  some  disturbance  of  the 
inhibitory  centers  governing  the  sphincter  muscles.  A  similar  condition 
has  also  been  observed  in  a  case  of  syphilitic  disease  of  the  cord. 

While,  therefore,  the  large  majority  of  this  type  of  cases  may  be 
accounted  for  by  local  or  reflex  diseases,  there  is  still  a  certain  number 
in  which  these  do  not  exist.  They  are  due  to  diseases  of  the  nerves 
or  nerve  centers,  and  this  must  be  recognized  in  order  to  avoid  opera- 
tions which  will  do  more  harm  than  good. 

Treatment. — The  treatment  of  these  conditions  will,  of  course,  depend 
upon  their  cause.  Wherever  there  is  hypertrophy  with  spasm  of  the 
sphincter,  together  with  tenderness  and  pain,  one  should  not  hesitate 
to  follow  Mathews^s  advice  and  dilate  or  incise  this  muscle,  and  thus 
put  it  at  rest.  At  the  same  time,  if  there  are  hypertrophied  papillae 
or  hemorrhoids,  they  should  be  removed.  Ulceration  should  be  treated 
by  appropriate  measures,  such  as  are  indicated  in  the  chapter  upon 
this  subject.  In  those  cases  in  which  there  is  a  localized  area  of  in- 
flammation with  an  abrasion  in  the  mucous  membrane,  Mathews  and 
Allingham  have  both  obtained  excellent  results  by  the  application  of 
nitric  acid  or  nitrate  of  silver  to  the  spot;  tincture  of  iodine  serves  the 
same  purpose  without  producing  an  actual  ulceration,  such  as  always 
follows  the  application  of  the  severer  cauterizing  agents. 

When  the  condition  is  due  to  a  general  congestion  of  the  rectum, 
cold-water  irrigation  is  ordinarily  effectual.  Better  results  will  be  ob- 
tained in  these  cases  from  the  irrigation  than  from  the  simple  injection 
of  cold  water  into  the  rectum.  In  those  cases  in  which  the  cold  appli- 
cation does  not  produce  as  much  relief  as  expected,  alternating  hot  and 
cold  irrigations  will  often  succeed.    In  order  to  do  this  properly,  one 


928  THE  ANUS,  RECTUM,   AND   PELVIC  COLON 

should  have  a  Y-shaped  tip  connecting  the  irrigator  with  two  bags. 
The  hot  water  should  be  run  through  first  at  a  temperature  of  110°  to 
120°.  This  should  be  continued  for  about  ten  minutes,  when  the  cold 
current  should  be  turned  on,  and  this  continued  for  about  the  same 
period.  By  this  means  excellent  results  have  been  obtained  in  those 
cases  in  tvhich  there  was  dull  continuous  aching,  and  heaviness  about 
the  lower  end  of  the  rectum. 

Where  there  is  a  prolapsed  ovary,  much  benefit  may  be  derived  from 
placing  the  patient  in  the  knee-chest  posture,  and  placing  a  tube  in  the 
vagina  so  as  to  allow  this  canal  to  become  inflated  with  air,  which  will 
thus  carry  the  ovary  upward  and  lift  it  out  of  the  cul-de-sac,  provided 
there  is  no  adhesion.  If  in  this  position  the  physician  can  feel  the  pro- 
lapsed organ  by  means  of  the  finger  in  the  rectum,  it  will  indicate  an 
adhesion,  and  this  should  be  treated  by  proper  surgical  intervention. 

Some  of  these  cases  are  due  to  retroversion  and  prolapse  of  the 
uterus,  often  associated  with  adhesions  between  this  organ  and  the 
rectum.  "Where  the  uterus  can  be  lifted  up  and  replaced,  it  may  be 
held  in  position  by  a  properly  adjusted  pessaiy,  and  the  rectal  symptoms 
will  immediately  disappear.  If,  however,  there  are  adhesions,  these  must 
be  broken  up  and  the  uterus  drawn  up  into  its  position  by  shortening 
the  round  ligaments,  or  by  some  fixation  method. 

Where  there  is  a  large  hypertrophied  cervix,  with  laceration  and 
inflammation,  the  symptoms  are  frequently  expressed  in  rectal  uneasi- 
ness, pain  upon  movement  of  the  bowels  and  upon  walking,  and  some- 
times intense  neuralgia  around  the  lower  end  of  the  rectum;  often 
all  these  symptoms  disappear  entirely  after  the  amputation  of  the  cer- 
vix, or  even  after  a  properly  performed  trachelorrhaphy. 

It  is  a  good  practice  always  to  dilate  the  sphincter  whenever  an 
operation  for  lacerated  cervix  or  ruptured  perin^eum  is  done.  ]\Iuch  of 
the  discomfort  following  these  operations  is  due  to  spasm  of  this  muscle. 
If,  therefore,  it  is  well  dilated,  this  source  of  irritation  will  be  radically 
removed,  and  at  the  same  time  obscure  fissures  which  may  be  present 
will  be  cured. 

The  author  has  reported  elsewhere  a  number  of  cases  of  urethral 
and  bladder  affections  causing  rectal  symptoms  (X.  Y.  Polyclinic,  No- 
vember, 189-1,  and  ihid.,  September  15,  1896).  Where  such  conditions 
are  found  to  exist,  they  should  be  treated  before  resorting  to  any  opera- 
tions on  the  rectum.  The  influence  of  disease  or  small  foreign  bodies 
in  the  crypts  of  jNIorgagni  should  not  be  forgotten  in  the  treatment 
of  these  obscure  diseases.  The  writer  is  well  aware  that  these  little 
pockets  have  been  much  maligned  by  charlatans,  who  have  ascribed  to 
them  many  disorders  of  the  rectum  of  which  they  are  not  guilty.  Never- 
theless, they  do  occasionally  become  irritated,  and  when  such  is  the 


NERVOUS   OR   HYSTERICAL   RECTUM  929 

case  tliey  will  account  for  a  great  deal  of  pain  and  rectal  uneasiness. 
In  patients  who  suffer  with  s}'niptoms  such  as  have  been  described,  the 
rectum  should  never  be  exonerated  until  a  careful  search  of  every  one 
of  these  little  pockets  has  been  made.  If  in  such  an  examination  any 
one  of  them  is  found  to  be  the  seat  of  either  inflammation  or  arrest  of 
a  foreign  body,  it  should  be  slit  open,  the  body  removed,  and  the  in- 
flamed condition  treated. 

Occasionally  in  these  cases  one  finds  a  type  of  stricture  which  is 
not  ordinarily  described  in  books.  It  consists  in  a  fine,  thread-like 
band  that  extends  sometimes  half-way  or  more  around  the  rectum,  and 
which  is  not  easily  made  out  by  touch  unless  the  rectum  is  distended 
more  or  less.  The  author  has  seen  this  condition  four  times — thrice  in 
women  and  once  in  a  man.  In  two  of  the  cases  there  was  no  history 
of  any  operation  having  been  performed,  nor  of  any  inflammation  of 
the  rectum,  so  far  as  the  patient  knew.  In  one  a  small  tumor  had  been 
removed  from  the  posterior  wall  of  the  rectum  some  four  years  previ- 
ously, and  in  the  last  an  operation  had  been  done  by  the  writer  five  years 
previously  for  a  submucous  fistula.  In  neither  of  these  cases,  however, 
were  the  bands  confijied  to  the  lines  of  the  previous  incisions,  nor  did 
they  obstruct  the  caliber  materially.  They  appeared  when  the  part 
was  put  upon  the  stretch  like  a  small  thread  over  which  the  mucous 
membrane  could  be  moved.  Stretching  gave  some  relief,  but  it  was 
only  temporary.  In  all  of  them  permanent  relief  was  obtained  by 
dissecting  out  the  fibrous  cords  completely,  and  suturing  the  wound 
together.  Microscopic  examination  showed  one  of  these  bands  to  be 
of  a  purely  fibrous  nature,  and  not  a  nerve  as  was  suspected.  The 
treatment  of  those  cases  due  to  diseases  of  the  nerves  or  central  nervous 
system  can  not  be  entered  into  in  a  work  of  this  kind.  The  reader  is 
referred  to  books  on  neurolog}'  for  this. 

There  still  remains  a  certain  number  of  cases  in  which  no  organic 
disease  can  be  found  in  the  rectum,  pelvic  organs,  spinal  cord,  or  brain 
to  account  for  the  pain.  Most  of  these  cases  are  the  victims  of  anaemia 
and  nervous  exhaustion.  The  treatment  of  such  cases  consists  in  rest, 
forced  feeding,  tonics,  and  change  of  environment.  The  so-called  "  rest 
cure  "  of  Weir  Mitchell  will  generally  give  good  results. 

ISTerve  sedatives,  such  as  hyoscyamus,  asaf  oetida,  bromides,  and  sum- 
bul,  are  useful.  Excellent  results  sometimes  follow  the  use  of  the  com- 
pound sumbul  pill  advised  by  Goodell.  At  other  times  the  admin- 
istration of  viburnum  gives  the  most  relief.  Opium  is  contraindicated 
in  these  cases,  and,  so  far  as  iron  is  concerned,  its  tendency  to  produce 
constipation  overbalances  the  good  which  it  sometimes  serves  in  the 
ansemic.  Some  of  the  modern  preparations  which  do  not  so  act  may 
be  of  benefit,  bnt,  as  a  rule,  this  remedy  is  detrimental  in  rectal  diseases. 
59 


CHAPTER   XXV 

RECTO-COLONIC  ALIMENTATION  OR  RECTAL  FEEDING 

Rectal  alimentation  is  seldom  applicable  in  the  treatment  of  dis- 
eases of  the  rectum^  hut  the  teacher  in  this  line  is  so  often  consulted 
with  regard  to  the  formulas  and  means  of  carrying  out  this  method  of 
feeding  in  the  various  forms  of  chronic  and  acute  diseases  that  it 
seems  justifiable  to  give  a  short  resume  -of  this  subject.  It  is  by  no 
means  a  new  method,  for  nutrient  clysters  are  mentioned  in  the  works 
of  Galen  and  many  of  the  earlier  writers.  Not  until  1872,  however, 
when  Levibe  first  employed  pancreatic  extract  in  nutrient  enemas,  was 
the  method  placed  upon  a  scientific  basis.  From  this  time  forward  it 
was  recognized  that  the  colon  secreted  no  digestive  ferments,  that  its 
function  was  purely  an  absorptive  one,  and  that  nutrient  injections, 
in  order  to  be  of  the  greatest  benefit,  must  necessarilv  be  predigested 
and  fluid  in  character. 

The  more  knowledge  of  stomachic  and  intestinal  diseases,  especially 
of  the  functional  type,  that  has  been  gained,  the  wider  and  wiser  has 
the  application  of  rectal  feeding  been.  Eichhorst,  Huber,  Boas,  Plan- 
tenga.  Van  Valzah,  Einhorn,  Ewald,  and  Nothnagel  have  paid  much 
attention  to  this  subject,  and  the  following  directions  are  based  largely 
upon  their  experiments,  with  the  results  of  personal  experience.  Wlien- 
ever  it  is  necessary  to  give  functional  rest  to  the  upper  portion  of  the 
alimentary  canal,  whether  it  be  the  throat,  oesophagus,  or  stomach,  the 
temporary  abstinence  from  food  given  by  the  mouth  is  absolutely  neces- 
sary. Happily  in  such  cases,  a  sufficient  amount  of  nourishment  may 
be  absorbed  through  the  rectum  and  colon  with  which  to  prolong  life 
for  weeks  or  even  months. 

M.  Tournier  (Province  medicale,  1895,  ISTos.  29,  30)  and  Professor 
Lepine  (Semaine  medicale,  1895,  pp.  317,  389)  have  made  interesting 
experiments  in  this  line.  The  former  fed  a  patient  by  this  means  alone 
for  seventeen  days,  and  observed  no  wasting,  but,  on  the  contrary,  an 
increase  of  weight.  A.  P.  Gross  (Th.,  Paris,  1898)  has  collected  QQ 
cases,  in  which  exclusive  rectal  feeding  was  carried  out  in  the  treat- 
930 


RECTO-COLONIC  ALIMENTATION   OR  RECTAL  FEEDING        931 

ment  of  patients  suffering  from  various  forms  of  stomachic  disease; 
many  of  these  cases  gained  in  weight  while  undergoing  this  treatment; 
only  a  very  few  of  them  lost  at  all,  and  those  very  slightly.  He  states 
that  the  result  as  to  nourishment  seems  comparable  to  that  obtained 
from  the  milk  diet;  the  diseases  in  which  he  found  it  most  useful  were 
ulcers  of  the  stomach,  hypersecretion,  or  excessive  sensibility  of  the 
gastric  mucosa,  Eeichmann's  disease,  hyperchlorhydria,  stenosis  of  the 
pylorus,  vomiting  of  pregnancy,  neoplasms  of  the  stomach,  and  peri- 
gastritis. He  states  that  the  method  should  be  used  exclusively  in 
ulcerations  of  the  stomach,  in  cases  of  stenosis  of  the  pylorus,  hj^per- 
chlorhydria,  and  hypersecretion,  and  in  cases  of  dilatation  of  the  stom- 
ach with  inadequate  power  from  various  causes.  It  is  only  a  comple- 
mentary method  in  cases  of  carcinoma  and  incoercible  neuropathic  vom- 
iting. In  these  a  certain  amount  of  predigested  food  of  a  bland,  non- 
irritating  quality  may  be  administered  by  the  stomach,  but  the  quantity 
is  insufficient  to  maintain  strength,  and  therefore  it  should  be  supple- 
mented by  the  use  of  nutrient  enemata.  At  the  same  time  he  concludes 
that  in  the  majority  of  cases  exclusive  colonic  alimentation  is  preferable, 
because  the  mixed  feeding  often  seems  to  prevent  the  absorption  of  the 
nutrient  enemata.  The  length  of  time  which  such  treatment  should 
continue  in  these  stomachic  cases  is  about  twenty  days. 

In  surgical  operations  about  the  throat,  mouth,  larynx,  stomach,  and 
intestines,  this  method  of  feeding  is  of  the  utmost  importance,  and  the 
patient's  strength  may  be  very  equably  maintained  if  it  is  properly 
carried  out. 

There  are  two  explanations  of  the  methods  by  which  nutrient  ene- 
mata are  absorbed.  The  first  is  that  the  absorptive  power  of  the  rectum 
and  colon  is  adequate  to  take  up  the  food  in  sufficient  quantities  to 
support  life  and  strength.  The  other  is  that  these  nutrient  injections 
are  carried  by  reverse  peristalsis  through  the  Bauhinian  valve  and  into 
the  small  intestine,  where  they  are  further  digested  by  the  pancreatic 
and  biliary  secretions,  and  absorbed  by  the  villi  of  this  region.  This 
latter  theory  would  very  easily  explain  all  these  cases,  but  unfortunately 
this  retroperistalsis  is  the  exception  rather  than  the  rule.  Tournier 
gives  an  interesting  account  of  a  woman  to  whom  he  administered  ene- 
mata of  cod-liver  oil  in  the  morning,  and  who  vomited  distinct  globules 
of  oil  during  the  afternoon.  Lepine,  Grutzner,  and  Swiezinsky  have  all 
conducted  interesting  experiments  to  prove  that  substances  injected  in 
the  rectum  find  their  way  into  the  small  intestine  and  stomach  in  animals. 
Those  upon  men,  however,  are  absolutely  unsatisfactory.  Voit  and 
Bauer  recognize  the  possibility  of  fluid  substances  passing  from  the 
large  intestine  through  the  Bauhinian  valve  into  the  stomach;  never- 
theless, they  aver  that  it  is  an  indisputable  fact  that  the  large  pro- 


932  THE  ANUS,  RECTUM,   ANT>  PELVIC  COLON 

portiou  of  the  albuminoid  material  bO  injected  is  absorbed  in  the  colon 
itself.  As  further  evidence  of  this  fact,  the  author  may  state  from  his 
experience,  that  in  two  patients  in  which  right  inguinal  colotomies  were 
done  for  carcinoma  of  the  transverse  and  splenic  colon,  the  patients 
were  nourished  for  considerable  periods  of  time  by  the  use  of  nutrient 
enemata  on  account  of  secondary  and  reflex  involvement  of  the  stomach. 
In  these  cases  it  was  absolutely  impossible  for  the  alimentary  substance 
to  pass  beyond  the  artificial  anus,  and  consequently  the  nutrition  ob- 
tained was  beyond  question  due  to  the  absorption  from  the  colon  itself. 
The  experiments  of  Grutzner  and  Xencki  have  been  made  upon  rabbits, 
guinea-pigs,  and  dogs,  whose  intestinal  conformation  is  different  from 
that  of  a  man,  aside  from  the  fact  that  the  erect  posture  has  much 
to  do  with  the  movement  of  the  fluid  in  the  intestinal  canal.  Their 
conclusions,  therefore,  can  not  be  relied  upon  to  explain  the  subject 
of  nourishment  by  rectal  feeding. 

In  the  chapter  upon  constipation,  the  possibility  of  an  occasional 
passage  of  fluid  from  the  rectum  into  the  stomach  was  admitted,  but 
such  an  action  is  ver}'  far  from  being  the  normal  course  of  events. 
Xumerous  experiments  upon  patients  with  artificial  ani  convinces  one 
that  the  large  proportion  of  the  fluid  material  injected  in  the  rectum 
or  colon  is  either  absorbed  by  that  organ  or  passed  out  through  the 
anal  canal.  These  experiments  seem  to  do  away,  then,  with  the  possi- 
bility of  the  digestion  of  the  nutrient  enemas  after  they  have  been 
injected  into  the  intestinal  canal.  It  is  of  the  utmost  importance,  there- 
fore, that  the  substances  used  for  this  purpose  should  be  either  pre- 
digested  or  ready  for  direct  absorption. 

It  has  been  demonstrated  by  Leube,  Huber,  and  Ewald  that  proteids 
are  fairly  well  absorbed  by  the  large  intestine.  The  results  of  their  ex- 
periments show:  First,  milk  proteids  are  not  very  well  absorbed;  second, 
eggs  given  alone  are  not  well  absorbed,  but  if  20  grains  of  salt  be  added  to 
each  egg  the  results  will  be  as  satisfactory  as  if  they  had  been  peptonized; 
third,  raw  beef -juice  is  well  absorbed;  fourth,  peptones  are"well  absorbed; 
fifth,  glucose  is  well  absorbed  if  it  is  not  in  concentrated  solutions,  in 
which  case  it  irritates  the  mucous  membrane,  and  is  likely  to  be  expelled 
before  absorption  takes  place,  so  that  Leube  advises  that  it  should  not  be 
used  in  stronger  than  lo-per-eent  solution,  nor  in  greater  quantity  than 
300  cubic  centimeters;  sixth,  starch  is  very  well  absorbed,  even  in  the 
raw  state,  and  is  not  irritating.  Fats  are  not  well  absorbed,  this  depend- 
ing upon  the  quantity  administered,  the  time  that  they  remain  in  the 
bowel,  the  presence  or  absence  of  salt,  and  the  temperature;  under  the 
most  favorable  circumstances  not  more  than  10  grammes  of  fat  can  be 
absorbed  in  one  day;  seventh,  alcohol  in  the  form  of  wine,  whisky,  or 
brandy,  well  diluted,  is  quickly  and  completely  absorbed.    From  these 


RECTO-COLONIC  ALIMENTATION  OR  RECTAL  FEEDING        933 

experiments  it  may  be  concluded  tliat  the  most  satisfactory  substances 
for  rectal  alimentation  are,  first,  alcohol;  second,  albuminose  or  pep- 
tones, eggs  with  salt;  third,  beef-juice,  unboiled  starch,  and  diluted 
solutions  of  grape-sugar.  Milk,  while  not  freely  absorbed  in  its  raw 
state,  when  peptonized  forms  the  best  basis  or  menstruum  for  all  ene- 
mata.  Somatose  may  be  substituted  for  peptone,  as  may  also  Valentine's 
beef-juice  and  beef  peptonoids. 

Eed  wine  has  been  recommended  by  a  large  number  of  European 
writers  as  a  satisfactory  method  of  administering  alcohol  by  enemas 
owing  to  its  astringency  as  well  as  its  acidity,  thus  contributing  to  their 
retention  in  the  intestine.  Fresh  blood  has  been  advocated  by  a  num- 
ber of  writers,  especially  by  Eicketts,  of  Cincinnati,  who  uses  from 
5  to  10  ounces  daily  of  defibrinated  beef  blood,  which  must  be  obtained 
fresh  every  morning.  He  reports  having  kept  a  patient  alive  for  six 
weeks  upon  this  treatment,  and  having  finally  obtained  a  very  satisfac- 
tory result.  Andrew  Smith  (Bull,  of  Academy  of  Med.,  Xew  York,  1879, 
p.  123),  as  chairman  of  a  committee  appointed  to  investigate  this  sub- 
ject, reported  a  number  of  observations  in  which  enemata  of  defibrinated 
beef  blood  had  been  used  in  different  pathological  conditions;  many  of 
these  were  tubercular,  others  carcinomatous,  and  others  in  advanced 
stages  of  chronic  disease;  the  results  in  the  majority  of  instances  were 
exceedingly  good;  in  a  few  cases,  however,  the  patients  not  only  did  not 
improve,  but  were  rendered  worse  by  the  treatment.  This  form  of  rectal 
alimentation  does  not  seem  to  have  established  any  great  superiority 
over  the  other  forms,  and  at  the  same  time  it  is  very  inconvenient,  and 
often  impossible  to  obtain. 

Eecently  French  therapeutists  have  obtained  some  very  excellent 
results  by  the  use  of  organo-serum  for  nutrient  enemata,  esj^eciall}'  in 
cases  of  nervous  exhaustion  and  inability  to  retain  food  from  one  cause 
or  another;  this  substance  possesses  excellent  tonic  effects,  and  in  cases 
where  it  is  impossible  to  administer  sufficient  nourishment  by  the  mouth, 
one  may  supplement  this  by  injections  of  organo-serum,  with  permanent 
and  decided  benefit. 

In  deciding  upon  rectal  alimentation,  one  should  always  consider 
what  elements  are  most  necessary  in  the  individual  case.  In  acute  ex- 
haustion from  haemorrhage,  overwork,  or  nausea,  where  stimulation  and 
filling  of  the  blood-vessels  are  indicated  rather  than  actual  nourish- 
ment, one  should  have  recourse  to  enemas  of  hot  normal  saline  solu- 
tion, with  small  quantities  of  red  wine,  whisky,  or  coffee.  In  shock 
and  collapse,  whether  from  surgical  operations,  injuries,  or  other  causes, 
great  benefit  may  be  obtained  from  an  injection  of  1  pint  of  hot  black 
coffee. 
,  Where  the  case  is  one  of  chronic  disease,  in  which  the  enema  is  not 


934  THE  ANUS,  RECTUM,  AND  PELVIC  COLON 

intended  for  temporary  purposes  but  as  a  means  of  permanent  feeding, 
the  stimulating  portion  of  the  enema  should  be  left  out,  inasmuch  as 
it  is  likely  to  irritate  the  mucous  membrane  of  the  intestine  and  render 
it  intolerant  of  the  injection.  A  good  formula  for  rectal  feeding  is  a 
mixture  of  3  eggs,  |  a  teaspoonful  of  salt,  G  ounces  of  peptonized  milk, 
with  or  without  a  tablespoonful  of  beef-juice  or  beef  peptonoids,  1 
tablespoonful  of  good  rye  whisky. 

Gross  recommends  the  formulas  of  Ewald  and  Boas  in  the  majority 
of  cases. 

Ewald's  formula  is:  Two  to  3  eggs,  1  glass  of  red  wine,  1  cup  of 
20-per-cent  solution  of  grape-sugar,  3  or  3  grains  of  salt. 

Boas's  formula  is  as  follows: 

Milk 250  c.c; 

Yolk  of  egg 2; 

Salt   1  pinch; 

Eed  wine 15  c.c. 

A  little  starch  may  be  added  to  this. 

The  methods  of  administering  nutrient  enemata  vary  considerably. 
It  is  important  in  all  cases  that  the  bowels  should  be  cleaned  out  at 
least  once  in  twenty-four  hours  when  rectal  alimentation  is  being  car- 
ried on,  and  this  is  best  accomplished  by  large  saline  enemas,  which  act 
more  effectually  if  administered  cold,  though  Ewald,  Tournier,  and 
Gross  prefer  to  use  them  hot.  The  cold,  however,  acts  more  promptly, 
and  the  bowel  seems  to  be  more  tolerant  of  the  nutrient  enema  after 
them  than  after  the  hot  ones.  The  amount  of  the  nutrient  enemas  can 
not  be  laid  down  by  any  hard-and-fast  rule;  some  patients  will  retain 
6,  8,  and  10  ounces,  while  others  can  not  retain  more  than  3  or  4 
ounces.  Where  the  patient  will  retain  as  much  as  8  ounces  at  one  time, 
the  enema  should  be  administered  not  oftener  than  four  times  in  twen- 
ty-four hours.  When,  however,  only  3  ounces  can  be  retained,  they 
should  be  administered  more  frequently.  Occasionally  it  Avill  be  neces- 
sary to  add  a  little  opium  to  the  enema  in  order  to  quiet  the  sensibility 
of  the  mucous  membrane  of  the  intestine.  The  quantity  necessary, 
however,  is  generally  quite  small,  4  to  5  drops  of  laudanum  being  ordi- 
narily sufficient.  This  use  of  opium  becomes  more  necessary  after  the 
process  has  been  carried  on  for  some  days,  and  it  may  be  necessary 
to  increase  the  quantity  from  day  to  day. 

As  to  how  long  rectal  alimentation  may  be  continued  can  not  be 
stated.  Hutchinson  claims  that  it  is  impossible  to  develop  more  than 
500  calorics  of  energy  daily  by  this  means,  whereas  at  least  1,500  are 
required  by  patients  to  maintain  the  equilibrium  of  health.  The  experi- 
ences of  Tournier,  Gross,  Ewald,  and  others  do  not  bear  him  out  in  this 


RECTO-COLONIC  ALIMENTATION  OR  RECTAL  FEEDING        935 

statement.  A  patient  has  been  kept  alive  by  this  method  twenty-six  days, 
so  that  an  extensive  gastric  ulcer  has  been  cured  because  of  the  func- 
tional rest  to  the  stomach;  she  lost  flesh,  but  was  no  more  emaciated 
than  one  often  finds  after  attacks  of  typhoid  or  other  acute  diseases. 
In  the  last  five  or  six  days  of  her  treatment  she  was  able  to  take  about 
2  ounces  of  peptonized  milk  daily  by  the  stomach. 

In  another  instance  of  gastroptosis  with  ulceration  and  severe  haem- 
orrhages, the  patient  was  fed  by  nutrient  enemata  for  eighteen  days 
exclusively.  When  the  treatment  was  begun  the  patient  was  practically 
pulseless,  emaciated,  and  collapsed,  following  a  severe  haemorrhage.  At 
the  end  of  eighteen  days  his  pulse  was  full  and  round,  70  beats  per 
minute,  his  respiration  normal,  his  body  had  filled  out,  and  he  was  able 
to  walk  several  blocks.  He  finally  resumed  taking  food  in  the  normal 
manner  and  lived  one  year  comparatively  comfortably,  when  suddenly 
the  old  condition  redeveloped  with,  at  the  same  time,  an  abnormal  irrita- 
bility of  the  rectum,  which  rendered  the  organ  intolerant  of  the  nutrient 
enemata,  and  it  could  not  be  made  so,  even  by  the  use  of  opiates  in 
large  quantities.  The  patient  being  unable  to  take  nourishment,  either 
normally  or  artificially,  succumbed.  As  a  rule,  however,  one  may  say 
that  twenty  days  will  probably  cover  the  average  period  in  which  ex- 
clusive rectal  alimentation  may  be  carried  out. 

The  method  of  administering  these  clysters  is  as  follows:  The  pa- 
tient is  laid  in  the  Sims's  position,  with  the  hips  elevated  upon  one  or 
two  pillows.  A  No.  5  Wales  bougie  is  then  introduced  into  the  rectum, 
and  whatever  gas  is  contained  in  this  organ  is  allowed  to  escape  through 
its  opening.  The  bougie  should  be  introduced  to  the  distance  of  3^ 
inches,  or  just  high  enough  to  be  entirely  above  the  sphincteric  con- 
traction. 

Some  writers  advise  injecting  the  nutrient  fluid  into  the  sigmoid 
flexure;  but  this  method  is  much  more  likely  to  excite  peristaltic  action 
and  ejection  of  the  fluid  than  if  it  is  poured  into  the  ampulla  of  the 
rectum  and  allowed  to  find  its  way  upward. 

The  fluid  should  also  be  injected  very  slowly;  if  given  from  a  foun- 
tain syringe,  the  bag  should  not  be  raised  more  than  2  feet  above  the 
level  of  the  patient's  hips.  The  small  soft  tube  is  important  in  order 
to  avoid  injury  to  the  parts  about  the  anus,  and  also  because  it  does  not 
stretch  the  parts  and  produce  a  tenderness  which  might  militate  against 
prolonged  treatment  by  this  method.  The  fluid  should  be  heated  to 
100°  Fahrenheit.  Cold  or  very  hot  solutions  always  excite  peristaltic 
action,  and  are  not  suitable  for  this  method  of  treatment. 

The  following  formula?,  given  by  the  most  noted  writers  upon  this 
subject,  may  be  of  interest  to  our  readers,  as  many  of  them  differ  from 
those  heretofore  given,  and  may  be  applicable  to  special  cases: 


936  THE  ANQS,  RECTUM,  AND  PELVIC  COLON 

Eiegl's  formula: 

Milk 250  c.c; 

Eggs 2  to  3; 

Salt 2  to  3  pinches; 

Red  wine 30  grammes. 

Catillou's  formula: 

Beef  peptone  (saturated  solution) 50  grammes; 

Water 125  grammes; 

Bicarbonate  of  soda 30  centigr.; 

Laudanum 4  drops. 

Tournier : 

Salted  bouillon 140  to  150  grammes; 

Yolk  of  egg  2; 

Wine 20  to  40  grannnes; 

Sydenham's  laudanum 4  to  8  drops. 

Tournier: 

Milk   140  grammes; 

Yolk  of  egg 2; 

Sugar 10  grammes; 

Laudanum    4  to  8  drops, 

Tournier: 

Bouillon 140  grammes; 

Yolk  of  egg 6; 

Wine    20  grammes; 

Salt 2  teaspoonf uls. 

Tournier: 

\\  ater 150  grammes; 

Dry  peptone 10  grammes; 

Yolk  of  egg 1- 

Glucose    20  grammes; 

Sydenham's  laudanum 4  drops. 

Professor  Jaccoud's  formula: 

Bouillon 250  grammes; 

**i^6    150  grammes; 

Yolk  of  egg  2; 

Dry  peptone   4  to  20  grammes. 


RECTO-COLONIC   ALIMENTATION   OR  RECTAL  FEEDIXG        937 

Lathier  employs: 

Dry  peptone   3  teaspoonf uls; 

Yolk  of  egg 1; 

^lili^   125  grarames; 

Tincture  of  opium  5  drops; 

Starch-powder    5  grammes. ' 

Adamkiewicz  recommends: 

Dry  peptone 100  grammes; 

Flour   300  grammes; 

Oil    90  grammes; 

Salt    30  grarames; 

Bouillon     1,000  grammes. 

In  several  injections. 

Fleiner: 

Bouillon 200  grammes; 

White  wine 50  grammes. 

Singer  uses: 

Milk 125  grammes; 

Wine    125  grammes; 

Yolk  of  egg  1; 

Salt 2  grammes; 

Witt's  dry  peptone 1  teaspoonful; 

Glucose    2  grammes. 

Schlesinger  employs : 

Milk   200  grammes; 

Eggs 2; 

Wine 15  grammes; 

Eice  flour   6  graimnes; 

Salt    3  pinches. 

Eat  Jen  uses: 

■^l{l^   250  grammes; 

Yolk  of  egg  ^' 

Salt    1  Pii^ch; 

Eed  wine 15  grammes; 

Starch   IS  grammes. 


INDEX 


Abbott,  ocular  examination  of  rectum,  126. 
Abdominal  extirpation  of  rectum,  836. 
Abdomino-anal  extirpation  of  rectum,  842. 
Abdomino-perineal  extirpation  of  rectum, 

847. 
Abdomino-sacral  extirpation  of  rectum,  845. 
Abnormalities  of  anus,  50. 
Abscess,  319. 

after  operation  for  hismorrhoids,  664. 

as  cause  of  fistula,  356. 

aspiration  of,  336,  347. 

bacteria  in,  330. 

circumscribed,  324. 

dilatation  of  sphincter  for,  338. 

dysuria  in,  335. 

escape  of  gases  from,  335. 

etiologj%  333. 

fffical  odor  from,  335. 

frequency  of,  331. 

gauze  drains,  347. 

Hartmann's  operation,  33V . 

interstitial,  339. 

intramural,  329. 

ischio-rectal,  324,  331. 

marginal,  322,  323. 

multilocular,  331. 

perianal,  319. 

course  of  infection,  324. 

etiology  of,  319. 
perirectal,  319. 

course  of  infection,  321. 

diffuse,  324. 

dilatation  of  sphincter,  338. 

superficial,  324. 

thrombosis  of  lymphatics,  323. 
phlegmonous,  329. 
posterior  communication,  332. 
profound,  324,  339. 

interstitial,  324. 

retro-rectal,  339. 

superior  pelvi-rectal,  342. 
remote  results  of,  345. 
repair  of,  337. 
retro-rectal,  339,  340. 
source  of  infection,  332. 


Abscess,  submucous,  329. 
subtegumentary,  324,  327. 
superficial,  325. 
symptoms,  334. 
tegumentary,  325. 
treatment,  336. 
Accelerator  urinse  muscle,  6. 
Achard,  perirectal  abscesses,  321. 
Ackland,  colitis,  180. 

trophic  ulceration,  288. 
Actinomycosis  of  anus,  757. 
Adamkiewicz's  formula,  937. 
Adeno-carcinoma,  768. 
Adeno-cj'stoma,  755. 
Adenoma  of  rectum,  722. 
malignant,  768. 
multiple,  725. 
etiology,  726. 
pathology  of,  733. 
symptoms  of,  730. 
treatment  of,  734. 
simple,  723. 

histology  of,  724. 
symptoms  of,  725. 
treatment  of,  725. 
Adler,  pruritus  ani,  578. 
Afezon,  lipoma  of  rectum,  718. 
Agnew,  D.  H.,  hsemorrhoids,  635. 
Agnew,  injection  of  liEemorrhoids,  624. 
Ainsworth,  malformations,  91. 
Alimentary  canal,  1 . 
development  of,  1. 
Alimentation,  recto-colonic,  930. 
Allingham,  atmospheric  ballooning  of  rec- 
tum, 118. 
colostomy  for  stricture,  512. 
in  carcinoma,  796. 
inguinal,  873. 
lumbar,  860. 
dysenteric  stricture,  481. 
extirpation  of  rectum,  815. 
forceps,  647. 

hemorrhoidal  crusher,  646. 
hEemorrhoids,  635. 
ligation  of  haemorrhoids,  633. 

939 


940 


THE  AXUS.   RECTUM,   AND   PELVIC   COLON 


Allingham,  lupoid  ulceration,  201. 

operation  for  prolapse  of  rectum,  686. 

procidentia,  667. 

pruritus  ani,  569,  579. 

rodent  ulcer,  263. 

tuberculo.sis,  199,  360. 

venereal  diseases,  213. 

villous  tumors,  738. 
American  operation  for  lisemorrhoids,  658. 
Amceba  dysenteria,  158. 
Amcebic  dj-sentery,  161. 
Amputation  of  rectum,  700. 

for  prolapse,  698. 

Fowler's  method,  700. 

Mikulicz's  method,  699. 
Amussat,  malformations  of  rectum,  59,  70, 
76. 

lumbar  colostomy,  863. 
Aniesthesia  complications,  410. 

in  examinations,  120,  138. 

in  rectal  diseases,  138,  631. 
Anal  canal,  7. 

description  of,  7. 

dimensions  of,  8. 

position  of,  7. 

relations  of,  13. 
Anal  cul-de-sac,  79. 

rhaphe,  S. 
Anders,  malformations,  83. 
Anderson,  nerves  of  anus  and  rectum,  33. 
Andrews,  anatomy  of  rectum,  9. 

bougie,  130. 

injection  of  hijemorrhoids,  622. 

speculiim,  117. 
Angeioma  of  rectum,  754. 
Ano-rectal  sj-philoma,  248. 
Anoscope,  Kelly's,  119. 
Anus,  1,  7. 

abnormahties  of,  49,  etc. 

absence  of,  49. 

actinomycosis  of,  757. 

artificial,  859. 
closure  of,  882. 
control  of,  886. 
inguinal,  865. 
lumbar,  863. 
permanent,  886. 
temporary,  877. 

atresia  of,  51. 

treatment  of,  84. 

blennorrhagia  of,  213. 

chancre  of,  230. 

chancroid  of,  219. 

complete  occlusion  of,  85. 
definition,  1. 

dermoid  cyst  in,  752. 

dimensions  of,  8. 


Anus,  eczema  of,  261. 

embryonic,  3. 

entire  absence  of,  49. 

fissure  of,  291. 

functions  of,  44. 

herpes  of,  260. 

imperforate,  54. 
colotomy,  80. 
mortality  from  operation  for,  S3. 

intolerable  ulcers  of,  291. 

irritable  ulcers  of,  291. 

lupoid  ulceration  of,  199. 

lymphatics  of,  34. 

malformations  of,  47. 
treatment  of,  68  et  seq. 

nerve  supply  of,  33. 

obstruction  of,  by  diaphragm,  54, 

occlusion  of,  partial,  53. 
treatment,  85. 

physiology,  43. 

position,  7. 

spinal  nerves,  34. 

tuberculosis,  192. 

ulcerations  of,  264. 

vaginal,  90. 

verrucous  ulcerations  of,  204. 
Applicators,  127. 
Archocele,  676. 
Arteries  of  anus  and  rectum,  29. 

inferior  hsemorrhoidal,  30. 

middle  haemorrhoidal,  30. 

sacral,  30. 

sigmoidal,  42. 

superior  haemorrhoidal,  29. 
Artificial  anus.     See  Anus. 
AschofE,  colitis,  188. 
Ashhurst,  haemorrhoids,  635. 
Ashby,  tuberculosis,  209. 
Atresia  ani,  62. 

ani  urethrahs,  63. 

uterinse,  62,  67. 

vaginalis,  64,  67. 

vesicalis,  62,  63. 
Aveling,  malformations,  91. 

Bacillus,  136. 

serogenes  capsulatus,  136. 

cholera,  136. 

coli  communis,  136. 

dysenterise,  158. 

Klebs-Loeffler,  166. 

lactis  serogenes,  136. 

of  tetanus,  136. 

of  tuberculosis,  136. 

of  typhoid,  136. 

pyocyaneus,  136. 
Bacon,  lateral  entero-anastomosis,  510. 


INDEX 


941 


Bacteria,  135. 
Bacterium  coli,  320. 
Bailey,  malformations,  87. 

permanent  inguinal  colostom.y,  888. 
Ball,  ano-rectal  sj-philoma,  248. 

cause  of  stricture,  473. 

congenital  s>TDhilis,  255. 

follicular  ulceration,  281. 

foreign  bodies,  899. 

gummata  of  rectum,  244. 

hsemorrhoids,  605. 

lipoma  of  rectum,  719. 

lupoid  ulceration,  201. 

h'mphadenoma,  721 . 

malformations,  24,  58,  61,  66,  91. 

sarcoma,  808. 

spasmodic  stricture,  462. 

theory  of  fissure,  295. 

treatment  of  stricture,  499. 

white  hEemorrhoids,  609. 
Ballance,  recto-vesical  fistula,  439. 
Bamburger,  follicular  ulceration,  282. 
Bangs,  hydatids,  758. 
Bardenheuer's  operation,  822. 
Barker,  angeioma,  755. 

dermoid  cj'sts,  748. 
Barlow,  colitis,  182. 
Barnes,  chronic  constipation,  547. 

fibroma  of  rectum,  716. 
Bartels,  recto-vesical  fistula,  438. 
Bassereau,  chancre,  228. 
Basset,  dysenterj-,  159. 
Batt,  inguinal  colostomy,  862. 
Bauhinian  valve,  536. 
Bazel,  dermoid  cj^sts,  748. 
Beach's  sigmoidoscope,  121. 
Beard,  stricture,  501. 
Beaumetz,  chronic  constipation,  547. 
Bender,  lupoid  ulceration,  201,  204. 
Benham's  hsemorrhoidal  crusher,  645. 
Bennett,  malformations,  60. 
Berg,  myoma  of  rectum,  720. 
Bernard,  recto-urethral  fistula,  429. 

venereal  diseases,  213. 
Bernays's  operation,  887. 

case  of  sarcoma,  808. 
Besnier,  lupoid  ulceration,  202,  203. 
Bidder,  entero-uterine  fistula,  447. 
Billingslea,  foreign  bodies,  90S. 
Billroth,  hyperplastic  tuberculosis,  211. 

venereal  diseases,  213. 
Bladder,  relations  to  rectima,  38. 

essential  gas  in,  441. 

rectum  communicating  with,  88. 
Blake,  venereal  diseases,  217. 
Blot,  hydatids,  758. 
Blunt-hooks,  127. 


Boas' s  formula  for  recto-colonic  alimenta- 
tion, 934. 
Bodenhamer,  congenital  sj-phihs,  255. 

malformations,  58  et  seq. 
Bodine,  inguinal  colostomj^,  874. 
Boeckel,  extirpation  of  the  rectum,  846. 
Bolton,  cohtis,  192. 
Bone-fiap  operation,  831. 
Bose,  lipoma  of  rectiun,  718. 
Bouchard,  relations  of  the  sigmoid,  43. 
Bougies,  128. 

a  boule,  129. 

Crede's,  496. 

in  stricture,  490,  496, 

retention  of,  498. 

Wales's,  128. 

Wyeth's,  129. 
Bouisson,  malformations,  47. 
Bowlby,  fibronia  of  the  rectum,  716. 
Boyer,  theory  of  fissure,  295. 

incision,  310. 

treatment,  306. 
Branca,  adenoma,  723. 

hmiphadenoma,  721. 
Braun,  permanent  colostomy,  888. 
Breschat,  malformations,  69. 
Briggs,  foreign  bodies,  907. 
BrinckerhofE's  speculum,  115. 
Bristow,  colitis,  180. 

extirpation  of  rectum,  832. 
Broca,  lipoma  of  rectmn,  718. 

perirectal  stricture,  466. 
Brodie,  fissure,  292. 

grooved  director,  387. 

hsemorr holds,  635. 
Brown,    Tilden,    case   of  rectal  ulceration, 

162. 
Brunn,  rectal  hernia,  706. 
Bryant,  foreign  bodies,  913. 

lumbar  colostomy,  863. 

mortaUty  from  colostomy',  861. 

prolapse  of  rectum,  695. 
Buchanan,  catarrhal  diseases,  164. 
Buckmaster,  malformations,  65,  91. 
Buffet,  foreign  bodies,  901. 
Bumm,  venereal  diseases,  214. 
Bumstead,  gummata  of  rectum,  244. 

venereal  diseases,  213. 
Burnier,  wounds  of  rectum,  916. 
Burn's  tenaculum,  127. 
Bushe,  malformations  of  rectum,  59. 
Byford,  vaginal  extirpation  of  rectum,  832. 

Cabot,  chronic  constipation,  547. 
Calbet,  extra-rectal  dermoids,  750. 

sacro-coccygeal  tumors,  754. 
Callisen,  lumbar  colostomy,  863. 


042 


THE   AXrS,    RECTUM.   AXD   PELVIC   COLOX 


CampbeU,  colitis,  180,  181. 
Campbell,  John,  on  malformations,  6U. 
Campenon,  vaginal  extirpation  of  the  rec- 
tum, 832. 
Canal,  anal.     See  Anal  canal. 
Cancer.     See  also  Carcinoma. 
Cancer,  760. 

acinous,  770. 

juice,  769. 

pearls,  767. 

scirrhous,  770. 

skin,  767. 

soft,  770. 
Canton,  foreign  bodies,  907. 
Caradec,  malformations,  66. 
Carcinoma.  760. 

abscess  from,  777. 

adenoid,  768. 

metastasis  of,  769. 

age,  influence  of,  764. 

anuria,  due  to,  776. 

cauterization  of,  795. 

changes  in  tj-pes,  766. 

colloid,  772. 

colostomy  for,  796. 

compatibility  with  good  health,  772. 

constitutional  symptoms,  775. 

curettage  for,  795. 

degenerative  stage,  776. 

diagnosis,  779. 

drugs,  treatment  by,  795. 

dysuria  from,  776. 

eneephaloid,  770. 

entero-anastomosis  for,  796. 

epithelial,  767. 

etiologj'  of,  763. 

excision  of  rectum,  prostate,  and  part  of 
bladder,  792. 

fibrous,  770. 

fistula  due  to,  777. 

general  sjTaptoms,  772. 

hsemorrhages,  774. 

hard,  770. 

heredity,  763. 

histological  tj-pes,  766. 

importance  of  early  examination,  772. 

indications  for  extirpation,  790. 

indications  in  treatment,  790. 

influence  of  sex,  765. 

inte.stinal  obstruction,  776. 

involvement  of  other  organs,  777. 

involvement  of  small  intestine,  779. 

laparotomy  in  diagnosis,  783. 

latent  period,  772. 

ligation  of  iliac  arteries,  846. 

lines  of  extension,  777. 

malignancy  of  different  varieties,  766. 


Carcinoma,  manual  exploration,  783. 

medullary,  770. 

metastasis,  779. 

morning  diarrhcca  in,  774. 

mortahty,  785. 

mucoid  degeneration,  772. 

obliteration  of  peritoneal  cul-de-sac,  778. 

occupation,  influence  of,  765. 

ocular  appear'.nce,  776. 

odor  from,  776. 

pain  from,  775. 

palliative  treatment,  794. 

patient's  rights,  792. 

perforation,  777. 

permanent  cure,  785. 

phototherapy,  779. 

prevalence  of,  760. 

previous  disease,  765. 

procidentia,  774. 

proUferative  stage,  773. 

results  of  treatment,  789. 

seat,  761. 

sepsis,  777. 

sources  of  error  in  diagnosis,  780. 

statistics  of,  786,  787. 

sj-mptoms  of,  772. 

syphilis,  766. 

treatment,  784. 

^'illous,  738. 

X-ray,  779. 
Camrick's  jjeptonoids,  145. 
Carpenter,  atmospheric  ballooning  of  rec- 
tum, 125. 
Carre,  excision  of  stricture,  506. 
Carrire,  chancre,  228. 

perirectal  abscesses,  320. 
Carson,  pruritus  ani,  578. 
Castellane,  lipoma  of  the  rectum,  718. 
Castex,  stricture  due  to  dysentery,  481. 
Casts  of  rectum,  16. 
Catarrh  of  rectimi  and  sigmoid,  139. 

acute,  141. 

atrophic,  152. 

hypertrophic,  146. 
Cathuart's  ointment,  615. 
Catillou's  formula  for  recto-colonic  alimen- 
tation, 936. 
Cautery,  Paquelin,  639. 
Chadwick,  circular  fibres,  20. 
Chair,  Martin's,  104. 
Chalmer,  prolonged  constipation,  518. 
Chalot,  extirpation  of  the  rectum,  846. 
Chancre,  228. 

anal,  230. 

complicating  haemorrhoids,  231. 
condylomata,  232. 
course  of,  232. 


INDEX 


943 


Chancre,  excision,  235. 
phagedenic,  231. 
treatment,  234. 

of  the  rectum,  232. 
cases  of,  233. 
symptoms,  234. 
treatment,  234. 
Chancroid,  219. 

anal,  221. 

complications,  227. 

distinguished  from  fissure,  221. 

etiology,  219. 

frequency  of,  219. 

multiple,  220. 

perianal,  220. 

phagedenic,  224. 

rectal,  223. 

septicaemia,  222. 

sjrmptoms,  223. 

treatment,  222,  224. 
Chaput,  extirpation  of  the  rectum,  845. 
Chassaignac,  excision  of  fistula,  391. 

hgemorrhoids,  645. 

subtegumentary  abscess,  327. 

thrombosis  of  the  lymphatic  trunks,  324. 
Cheselden,  excision  of  fistula,  391. 
Chetwood's  operation  for  incontinence,  417. 
Chiari,  tuberculosis,  192. 
Clamp  and  cautery  operation  for  piles,  637. 
Clamps,  639. 

Earle's  haemorrhoidal,  634. 

Gant's  haemorrhoidal,  639. 

Kelsey's  haemorrhoidal,  639. 

O'Hara's,  881. 

Ware's,  639. 
Clerk,  chancre,  228. 
Cloaca,  the,  2. 

Closmadeuc,  foreign  bodies,  900. 
Closure  of  artificial  anus,  882. 

author's  method,  884. 

end-to-end  union,  883. 

plastic  method,  884. 
Clover's  crutch,  641. 
Clutton,  dermoid  cysts,  748. 
Coactor,  500. 
Ccelum,  the,  2. 
Coleman,  colitis,  180. 
Coley,  case  of  malformations,  64. 
CoHtis,  167. 

chronic,  167. 

'•'colitis  cystica,"  188. 

etiology,  167. 

floating  kidney  causing,  170. 

follicular,  186. 
etiology,  186. 
pathology,  187. 
symptoms,  189. 


Colitis,  treatment,  190. 

inflammation  of  appendix  causing,  169. 

membranous,  167,  168-192. 

mucous,  167-192,  522. 

pathology,  171. 

pelvic  adhesions  causing,  168. 

reflex  causes,  168. 

secondary  membranous,  178-180. 

symptoms,  173. 

treatment,  175. 

ulcerative,  180. 

etiology,  180. 

pathology,  182. 

symptoms,  182. 

treatment,  184. 
valvular  colostomy  for,  191. 
Colles's  fascia,  5. 
Collins,  malformations,  47. 
Colon,  39,  42. 

congenital  hyperplasia  of,  536. 
dilatation  of,  536. 
pelvic,  39. 
Colopexy,  696. 

in  constipation,  554. 
Colorectostomy,  839. 

widening  of  the  gut  caliber,  840. 
Colostomy,  796,  859. 
abdominal,  860. 
inguinal,  866. 

Allingham's  method,  873. 

author's  method,  890. 

Bailey's  method,  889. 

Bodine's  method,  874. 

Braun's  method,  890. 

Cripp's  method,  872. 

fixation  of  gut,  871. 

indications  for,  868. 

Jeannel's  method,  875. 

Maydl-Reclus  method,  875. 

on  right  side,  892. 

permanent,  885. 

sphincteropoesis,  887. 

temporary,  868. 

valvular,  191. 

Witzel's  method,  888. 
in  stricture,  512. 
lumbar,  860,  863. 

Amussat's  operation,  863. 

Bryant's  method,  863,  864. 
mortality  from,  861. 
permanent,  885. 
preliminarj%  812. 
preparation  of  patient,  869. 
statistics  of,  862. 
technique  of  operation,  869. 
temporary,  868. 
valvular,  Gibson's,  191. 


944 


THE  ANUS,   RECTUM,   AND   PELVIC  COLON 


Colotomy,  859. 
for  stricture,  512. 
in  imperforate  ani,  80. 
Columns  of  Morgagni,  22. 

of  the  rectum,  22. 
Condylomata,  gonorrlural,  216. 

lata,  236. 
Connor,  manual  exploration,  112. 
Constipation,  517. 
acute,  543. 

symptoms,  543. 

treatment,  544. 
age,  influence  of,  526. 
as  cause  of  cancer,  766. 
a  symptom,  519. 

bladder  and  urethral  affections,  514. 
causes  exciting,  528. 
causes  predisposing,  526. 
changes  of  mucosa,  535. 
changes  of  submucosa,  535. 
chronic,  545. 

colopexy  for,  554. 

constitutional  effects,  546. 

diet  in,  552. 

electricity  for,  555. 

haemorrhoids  in,  557. 

Houston's  valves,  557. 

massage  for,  555. 

nervous  symptoms  from,  547. 

pneumatic  distention  in,  555. 

spasm  of  sphincter  in,  556. 

symptoms  of,  546. 

treatment  of,  548. 

valvotomy  for,  557. 
definition  of,  525. 
diagnosis,  542. 
due  to  circulatory  diseases,  531. 

digestive  disorders,  530. 

diseases  of  the  nervous  system,  531. 

drugs,  529. 

enteroptosis,  586. 

enterospasm,  532. 

flexure,  537. 

foreign  bodies,  539. 

intussusception  and  prolapse,  541. 

liver  disease,  531. 

malformations,  535. 

spasm  of  sphincter,  538. 
enlarged  prostate,  541. 
etiology,  526. 

extra-intestinal  obstructions,  540. 
fissure,  539. 

flexure  of  colon  causing,  537. 
food,  influence  of,  528. 
heredity,  526. 
influence  of  food,  528. 
intra-intestinal  tumors,  541. 


Constipation,  medicinal  treatment,  562. 

mental  symptoms,  547. 

occupation,  influence  of,  527. 

prolonged,  518. 

sex,  influence  of,  527. 

spasm  of  circular  fibers,  539. 

spastic,  532. 

\alvotoniy  for,  534,  558. 

^•ibrato^y  treatment  of,  556. 
Conus  meduUaris,  44. 
Cook's  speculum,  117. 
Cooper,  hiemorrhoids,  6.35. 
Copeland,  constipation,  535. 

hirmorrhoids,  635. 

incision  of  fissure,  310. 
Coproliths,  898. 

Coquet,  hyperplastic  tuberculosis,  211. 
"  Core  "  in  abscess,  325. 
Cornil,  stricture,  472. 
Councilman,  dy.sentery,  158. 
Couty,  malformations,  47,  84. 
Cowen,  trophic  ulceration,  288. 

colitis,  180. 
Cowper's  glands,  5,  6. 
Credo's  bougie,  498. 
Cripps,  absorptive  action  of  rectum,  45. 

adenoma  of  the  rectiun,  723. 

benign  strictures,  455. 

connective-tissue  hfemorrhoids,  603. 

extirpation  of  the  rectum,  814. 

inguinal  colostomy,  872. 

lupoid  ulceration  of  anus,  203. 

malformations,  75,  83. 

papilloma,  739. 

jirolapse,  667. 

recto-vesical  fistula,  440. 

simple  cj'sts,  747. 

spasmodic  stricture,  462. 

strictural  ulceration,  282. 

stricture  due  to  dysentery,  481. 

varicose  ulceration,  276. 

veins  of  rectum,  31. 
Croley,  lumbar  colotomy,  862. 
Cruikshanks,  dysentery,  158. 
Cruslier,  Allinghain's,  646. 

Benhani's  luemorrhoidal,  645. 

hsemorrhoidal,  645. 

Smith's,  647. 
Cruveilhier,  fistula,  356. 
Crypts  of  Morgagni,  23. 
Culs-de-sac,  22,  38. 

Douglas's,  41. 

peritoneal,  38. 

prostato-vesical,  38. 

treatment  of  anal,  79. 
Cunningham,  foreign  bodies,  906. 
Curling,  acute  catarrhal  proctitis,  143. 


INDEX 


945 


Curling,  colotomy  for  stricture,  512. 

hsemorrhoids,  635. 

incision  of  fissure,  310. 

malformations,  47,  83. 

obscure  diseases  of  the  rectum,  922. 
Cusack,  clamp  and  cautery,  operation,  637. 

hajmorrhoids,  621. 
Cystoma,  747. 
Cysts,  747. 

dermoid,  747, 
anal,  752. 
extra-rectal,  750. 
rectal,  749. 

simple,  747. 
Czerny,  extirpation  of  the  rectum,  845. 

recto-vaginal  fistula,  454. 

treatment  of  multiple  adenoma,  734. 

Da  Costa,  cohtis,  174,  178,  186. 
Dahlenkampf,  foreign  bodies,  906. 
Dandridge,  manual  exploration  of  rectum, 

111,  112. 
Deaver,  lymphatics  of  the  rectum,  36. 
De  earlier,  myoma,  720. 
Defecation,  519. 

colon,  522. 

influence  of  food,  520. 

influence  of  gases,  520. 

O'Beirne's  theory,  523. 

physiology  of,  520. 

remission  of  inclination  to,  525. 

reverse  peristalsis  in,  523. 

stimulants,  influence  of,  521. 
Degony,  malformations,  84. 
Delafield,  colitis,  180,  182,  186. 
Delbet,  hyperplastic  tuberculosis,  211. 

foreign  bodies,  901. 
Delorme,  operation  for  prolapse  of  rectum, 

688. 
Demarquay,  incision  of  fissure,  314. 
Dennis,  rodent  ulcers,  263. 
Dentu,  recto-urethral  fistula,  432. 
Depage,  extirpation  of  the  rectum,  814. 
Dernioids.     See  Cysts. 
Desault,  excision  of  stricture,  506. 

inguinal  anus,  867. 

treatment  of  stricture,  497. 
Desguins,  vaginal  extirpation  of  the  rec- 
tum, 832. 
Desnos,   stricture   from   prostatic   disease, 

467. 
Desprey,  marginal  abscesses,  322. 
Devillier,  prolonged  constipation,  518. 
Diagnosis,  94-138. 
Diarrhcea,  in  fsecal  impaction,  542. 

morning,  272. 
Dickinson,  nephritic  ulceration,  285. 

60 


Diday,  phagedenic  chancroid,  224. 
DiefEenbach,  extirpation  of  the  rectum,  814. 

imperforate  anus,  69. 
Dieffenbach-Roberts  operation  for  prolapse 

of  rectum,  689. 
Dilatation,  digital,  for  fissure,  306-310. 
Dilatation,  gradual,  for  stricture,  496. 

for  hseinorrhoids,  618. 
Dilators,  120. 

Kelly's  sphincter  (conical),  120. 

rectal,  500. 
Dimples,  postanal,  752. 
Dinet,  inguinal  anus,  867. 
Dionis,  malformations,  69. 
Diphtheria  of  rectum,  166. 
Dittel,  recto-vesical  fistula,  439. 
Divulsor,  Mathews'  rectal,  619. 
Dolbeau,  enchondroma  of  rectum,  717. 
Dolore,  actinomycosis  of  anus,  757. 
Douglas's  cul-de-sac,  22. 
Doyon,  phagedenic  chancroid,  224. 
Dressing  forceps,  127. 
Duboise,  inguinal  anus,  867. 
Ducrey,  venereal  diseases,  220. 
Duhring,  chancre,  229. 
Dumarquay,  recto-vaginal  fistula,  451. 
Duncan,  tuberculosis,  201. 
Dunglison,  proctocace,  351. 
Duplaiz,  verrucous  ulceration  of  anus,  205. 
Duplay,  etiology  of  stricture,  480. 
Dupres,  phagedenic  chancroid,  225. 
Dupuytren,  incision  of  fissure,  310. 
Duran-Borda,  fistula,  359. 
Durand,  Marius,  malformations,  69. 
Duret,  dermoid  cysts,  752. 

hsemorrhoidal  plexus,  31. 

operation  for  prolapse  of  rectum,  688. 
Duval,  bacillus  dysenterise,  158,  159. 
Dysentery,  158. 

amcebic,  162. 

diagnosis  of,  163. 
treatment  of,  163, 

bacillary,  160. 
diagnosis  of,  160. 
treatment  of,  160. 

d.  catarrhal,  160. 

etiology  of,  158. 

pseudo-bacillus  of,  159. 

symptoms,  161. 

treatment  of,  163. 

tropical,  159. 
Dysuria  in  ischio-rectal  abscess,  335. 

Earle,  on   acute  tubercular  inflammation, 
212. 
constipation,  560. 
hEemorrhoidal  forceps,  654. 


946 


THE   ANUS,   RECTUM,   AND  PELVIC  COLON 


Earle's  operation  for  piles,  654. 

vaginal  extirpation  of  the  rectum,  833. 
Ectod.     See  Epiblast. 
"  Ectropion  recti,"  142. 
Eczema  of  anus,  261. 

erj-thematous,  261. 

moist,  261. 

treatment,  261. 

vesiculosum,  261. 
Edebohls,  extirpation  of  the  rectum,  811. 
Edwards,  hypertrophied  valves,  535. 
Egineta,  malformations,  69. 
Einhorn,  colitis,  176,  178. 
Eldridge,  catarrhal  disea.ses  of  the  rectum, 

204. 
Electricity,  treatment  of  constipation,  555. 
Electrolysis   in   lupoid   ulceration  of  anus, 
204. 

for  varicose  piles,  654. 

in  stricture,  501. 
Embryology,  1. 
Enchondroma  of  rectum,  717. 
Endarteritis  in  syphilitic  stricture,  474. 
Endoscope,  121. 
Enema,  administration  of,  99. 

nutrient,  930. 

nutrient  formula?,  936. 
Engle,  relations  of  the  sigmoid,  43. 
Entero-anastomosis,  for  cancer,  17,  79. 

for  stricture,  510. 

O'Hara's  method,  883. 
Enteroliths,  132,  898. 
Enteron.     See  Hindgut. 
Enteroptosis,  536,  553. 
Enterospasm,  532. 
Epibla-st,  1,  3,  4. 
Episeiocleisis,  454. 
Epithelial  pegs,  767. 
Epithelioma  of  rectum,  767. 

appearance,  768. 

columnar,  768. 

cyUndrical,  768. 

discharge  from,  768. 

distinguished  from  rodent  ulcer,  768. 

limits,  768. 

seat,  768. 

squamous,  768. 

superficial,  vegetating,  738. 

symptoms,  768. 
Esmarch,  cicatricial  stricture,  465. 

lipoma  of  rectum,  718. 

perirectal  abscesses,  319. 

sarcoma,  808. 
Esthiomene,  200. 
Eurich,  colitis,  180. 

tropic  ulceration,  288. 
Evans,  ^Yilliam  A.,  rectal  valves,  26,  28. 


Ewald,  formula  for  recto-colonic  alimenta- 
tion, 934. 
Examination  in  rectal  diseases,  94-138. 
ana?sthesia  in,  120,  138. 
apparatus  for,  105. 
bougies,  128. 
digital,  107,  488. 
enemata  in,  99. 
external  appearances,  106. 
historical,   95. 
instrumental,  113-130. 
light,  113. 
local,  96. 
manual,  110. 
methods,  95. 
ocular,  125. 

limits  of,  126. 
of  caput  coli.  111. 
of  ficces,  131-138. 

bacteriological,  135-138. 

chemical,  136-138. 

methods  of,  131-138. 

microscopical,  133-135. 

Von  Jaksch,  133. 
pain  in,  97. 
postures  in,  101. 
preparation  of  patient,  98. 
protrusion,  97. 
state  of  bowels  at,  97. 
symptoms  suggesting,  96. 
vagino-rectal,  489. 
Excision  of  fistula,  391. 
of  haemorrhoids,  648. 
of  rectum,  prostate,  and  part  of  bladder, 

792. 
Extirpation  of  the  rectum,  810. 
abdominal  method,  836. 
abdomino-anal  method,  842. 
abdomino-perineal  method,  845. 
abdomino-sacral  method,  845. 
after-treatment  of  patient,  829. 
AUingham's  method,  815. 
anchoring  sutures,  828. 
artificial  anus,  853. 
Bardenheuer's  method,  822. 
bone-flap  operation,  824. 
cases,  839-840. 
causes  of  death,  788. 
choice  of  method,  855. 
colorectostomy,  839. 
combined  methods,  942. 
complications  following,  18,  51. 
concealed  haemorrhage  after,  829. 
control  of  hcemorrhage  in,  826. 
Cripps's  method,  814. 
diarrhoea  after,  855. 
disposition  of  intestinal  ends,  849. 


INDEX 


947 


Extirpation   of   the   rectum,    evolution    of, 
810. 
fistula  from,  828. 
functional  complications  following,  855. 

gangrene  following,  853. 

Gersuny's  method  to  prevent  incontinence 
after,  854. 

Hegar's  method,  822. 

Hochenegg's  method,  822. 

incontinence  following,  786,  854. 

indications  for,  790. 

infection  in,  852. 

influence  of  age  in,  788. 

injury  to  other  organs  in,  852. 

Kraske's  method,  821. 

length  of  life  after,  786. 

Levj^'s  method,  822. 

Maunsell's  method,  842. 

Murphy  button  in,  827,  850. 

Murphy's  method,  835. 

perineal  method,  813. 

preliminary  colostomy,  812. 

preliminary  curettage,  813. 

preparation  of  patient,  811. 

preparation  of  surgeon,  793. 

prolapse  following,  854. 

Quenu's  abdomino-perineal  method,  848. 

Quenu's  perineal  method,  817. 

Rehn-Rydygier  method,  824. 

relation  of  the  parts  involved,  825. 

results  of,  786,  841. 

Rose's  method,  822. 

Rj'dygier's   method  to   prevent  inconti- 
nence after,  854. 

sacral  method,  821. 

sepsis  following,  788,  789. 

statistics  of,  857. 

stricture  following,  854. 

treatment  of  intestinal  ends,  849 
the  bone  flap,  829. 
the  peritonaeum,  826. 

vaginal  method,  832. 

Van  Buren's  rule,  791. 

Von  Heineck's  method,  822. 

Weir's  method,  843. 

Willems's    method    to  prevent    inconti- 
nence after,  854. 

Faecal  impaction,  517,  564. 
Faecal  stones,  898. 
Faeces,  135. 

bacteriological  examination  of,  135. 

chemical  examination  of,  136. 

examination  of,  130. 

incontinence  of,  412. 

microscopical  examination  of,  133. 
Fascia,  superficial  perineal,  5. 


Fascia,  Colles's,  5. 

Fayard,  extension  of  carcinoma   778. 

Feeding,  rectal,  930. 

Fehling's  sugar  test,  138. 

Felizet,  Ivmphadenoma  of  rectum,  721. 

Ferguson,  speculum,  116. 

Feulard,  chancre,  229. 

Fibroma  of  anus  and  rectum,  716. 

pathology,  716. 
Fine,  artificial  anus,  867. 
Finet,  carcinoma,  765. 
Fink,  multiple  adenoma,  727. 
Finkler,  spirillum,  136. 
Fissure  in  ano,  291. 

as  cause  of  abscess,  332. 
author's  method  of  incision,  311. 
complications  of,  317. 
dilatation  for,  306. 

etiology  of,  293. 

excision  of,  314. 

extent  of  incision  in,  311. 

ichthyol  treatment  bj-,  305. 

incision  in,  310. 

incontinence  from  incision,  317. 

laxati\'es,  treatment  by,  303. 

location,  293. 

multiple,  291. 

non-operative  treatment,  306. 

operative  treatment,  306. 

pain  in,  298. 

pathology,  296. 

Pennington's  tube,  309. 

poh^jus  complicating,  294. 

reflex  sjTnptoms,  299. 

results  of  dilatation,  309 

sex,  influence  of,  293. 

shape,  292. 

stretching  of  sphincter,  treatment,  307. 

stricture  from,  317. 

submucous,  316. 

symptoms,  298. 

treatment,  302. 
Fistula,  353. 

after  operation  for  haemorrhoids,  664. 

age,  358. 

anatomical  character,  367. 

bimucous  anal,  367. 

bhnd  external,  362. 
diagnosis  of,  362. 
treatment,  389. 

bhnd  internal,  362. 
diagnosis  of,  363. 
sjTnptoms,  363. 
treatment,  398. 

burrowing,  post-operative,  419. 

chronicity,  357. 

classification,  353. 


948 


THE   ANUS.    RECTUM,    AND   PELVIC  COLON 


Fistula,  coniplefp,  354,  363. 

complex,  354,  367. 
diagnosis,  367. 
treatment,  400. 

complicated,  354,  421. 

complications   in    operations   for,  imme- 
diate, 408. 

complications  in  operations  for,  late,  412. 

connecting  rectum  with  other  organs,  423. 

constitutional  conditions,  359. 

course  of  burrowing,  401. 

danger  of  force  in  examination,  400. 

definition,  353. 

diagnosis,  364. 

due  to  carcinoma,  370. 

entero-vesical,  438,  443. 

etiology,  356. 

examination,  364. 

excision,  391,  453. 

excision  with  immediate  suture,  391. 

external  opening,  364. 

fistulotomy,  383. 

frequenc^^  of,  355. 

from  bone  disease,  421. 
osteosarcoma,  422. 
stricture,  370. 
wounds,  356. 

haemorrhage,  409. 

healing,  after  operation,  premature,  420. 

horseshoe,  404. 

importance  of  finding  pathological  inter- 
nal opening,  367. 

incomplete,  353. 

incontinence,  post-operative,  412. 

influence  of  tuberculosis,  359. 

injection  of  colored  fluids  in   diagnosis, 
366. 

instruments  for  operation,  387. 

internal  opening,  365. 

intra-anal,  367. 

intrarectal,  367. 

involuntary   defecation,    post-operative, 
411. 

ligature,  381. 

line  of  incision,  389. 

IjTiiphatic  thrombosLv,  357. 

movement  of  the  bowels  after  excision, 
396. 

non-operative  treatment,  378. 

non-specific,  355. 

operative  treatment,  384. 

origin,  368. 

osmosis  of  gases,  357. 

packing  of,  390. 

pathological  nature,  371. 

perineal,  424. 

position  for  operation,  386. 


Fistula,  premature  healing,  420. 

preparation  of  patient  for  operation,  384. 

progno.sis,  372. 

prolapse,  post-operative,  418. 

protracted  suppuration,  53. 

recto-genital,  446. 

recto-ureteral,  446 

recto-urethral,  425. 

recto-uterine,  446. 

author's  operation,  435. 

diagnosis,  428. 

etiology,  426. 

sj-mptoms,  428,  430. 

treatment,  430. 
recto-vaginal,  449. 

excision  of,  453. 

treatment,  450. 
recto-vesical,  430,  438. 

diagnosis,  440. 

etiology,  438. 

symptoms,  441. 

treatment,  444. 
recto-\'ulvar,  447. 
repair  of,  358. 
resulting  from  false  passage  in  urethra, 

370. 
retention  of  urine,  post-operative,  410. 
sex,  influence  of,  358. 
shock  following  operations,  411. 
specific,  355. 
spontaneous  cure,  373. 
subaponeurotic,  354. 
submucous,  354. 
submuco-cutaneous,  354. 
submuscular,  354. 
subtegumentary,  354,  422. 
suppuration,  post-operative,  419. 
sutures  and  ligatures,  388,  393. 
sj'mptoms,  361. 
syphilis,  361. 
tract,  365. 
treatment,  378. 
tubercular,  operation,  373. 

pathology,  375. 

statistics  of,  360. 
urethral,  resembling  ano-rectal,  369. 
urinary,  424. 
use  of  probe  in,  366. 
watering-pot,  403. 

with  multiple  internal  openings,  404. 
Fistulas,  why  they  do  not  heal,  357. 
Fistulotome,  Mathews',  384. 
Fistulotomy,  383. 

Fleiner's  formula  for  recto-colonic  alimen- 
tation, 937. 
Flexnc",  dysentery,  158,  159. 
Flexure,  of  sigmoid  acute,  537. 


INDEX 


949 


Fochier,   treatment  of  multiple  adenoma, 

735. 
Forceps,  alligator,  127. 

Allingham's,  647. 

artery,  387. 

Earle's,  654. 

fixation,  127. 
Forchung,  lipoma  of  rectum,  719. 
Fordyce,  rodent  ulcers,  263. 
Foreign  bodies  in  the  rectum,  894. 

accidental  introduction  of,  900. 

after-treatment  of  the  rectum,  911. 

arrest  of,  895. 

in  Houston's  folds,  902. 

cceliotomy  for,  911. 

complications  following,  905. 

constitutional  symptoms  following,  902. 

diagnosis,  904. 

fatalities  from,  913. 

genito-urinary  symptoms  of,  903. 

haemorrhages  from,  904,  907. 

instances  of,  895. 

in  transverse  colon,  900. 

introduced  through  anus,  899. 

Lefort's  suggestion,  910. 

Marchettis's  case,  909. 

m.ethod   of    ascending  into  the  sigmoid, 
910. 

method  of  entrance,  894. 

Moran's  case,  899. 

obstetric  forceps  in,  910. 

prognosis,  906. 

prolapse  of  rectum,  905,  910. 

results  of,  898. 

section  of  sphincter,  909. 

spontaneous  exit,  913. 

swallowed,  895. 

symptoms,  902. 

time  consumed  in  passage  through  the 
alimentary  tract,  896. 

treatment,  908. 

use  of  the  sigmoidoscope,  911. 
Forster,  papillary  tumors,  738. 
Fossa,  intersigmoidal,  40. 

ischio-rectal,  6,  7. 
Fournier,  ano-rectal  syphiloma,  248,  472. 

chancre,  228. 

gummata  of  anus,  244. 

stricture,  471. 

venereal  diseases,  219. 
Fowler,  amputation  of  rectum,  700. 

prolapse  of  rectum,  691. 
Franck's  pills,  563. 
Francou,  fistula,  356. 
Freer,  artificial  anus,  867. 
Freiind,  hydatids  of  rectum,  757. 
Friedberg,  malforniations  of  rectum,  58. 


Frisch,  venereal  diseases,  214. 
Fritsch,  recto-vaginal  fistula,  4.52. 
Fuchs,  proctocace,  351. 
Fuller,  recto-urethral  fistula,  433. 
Fulton,  etiology  of  stricture,  480. 
Fungus,  benign,  of  rectum,  756. 

ray,  756. 
Futcher  on  dysentery,  159. 

Gant,  clip  for  valves,  561. 

dermoid  cysts,  749. 

foreign  bodies,  899. 

gumma,  246. 

hemorrhoidal  clamp,  639. 

hgemorrhoidal  syringe,  628. 

lupoid  ulceration  of  anus,  203. 
Gases,  intestinal,  520. 
Gaudier,  extirpation  of  the  rectum,  845. 
Gay  and  Duval  on  dysentery,  158. 
Gaylord,  colitis,  188. 
Gentilhomme,  foreign  bodies,  913. 
Gerster,  idiopathic  gangrenous  periprocti- 
tis, 351. 

treatment  of  multiple  adenoma,  735. 
Gersuny,  operation  for  incontinence,  854, 
886. 

vaginal  extirpation  of  rectum,  833. 
Gibb,  case  of  postanal  dimple,  753. 
Gibbon,  idiopatliic  gangrenous  periprocti- 
tis, 350. 
Gibbs,  dysenteric  stricture,  481. 

varicose  ulceration,  276,  277. 
Gibson,  colitis,  192. 
Gillette,  sarcoma,  801. 

Giordono,  extirpation  of  the  rectum,  846. 
Girode,  stricture,  472. 
Glaeser,  colostomy  for  stricture,  512. 

excision  of  stricture,  506. 
Gland,  coccj'^geal,  4. 

of  Luschka,  38. 
Glands,  tubular,  9. 
Glasgow,  colitis,  175. 
Glisson,  pillars  of,  22. 
Godebert,  stricture,  483. 
Golding-Bird,  dermoid  cysts,  749. 
Gonococci  in  rectal  discharges,  214, 
Gonorrhcea  of  rectum,  214. 

cases,  214,  215. 

condylomata  following,  216. 

diagnosis,  216. 

dilatation  of  sphincter  for,  218. 

etiology,  215. 

hfemorrhoids,  216. 

prognosis,  217. 

submucous  fistula,  218. 

sjanptoms,  215. 

treatment,  217. 


950 


THE   ANUS,   RECTUM,   AND   PELVIC   COLON 


Goodell,  hysterical  rectum,  923. 
Goodsall  and  Miles,  extension  of  burrowing 
in  fistula,  420. 

fissure,  29  L 

haemorrhoids,  635. 

horseshoe  fistula,  407. 

internal  fibers  of  the  rectum,  21. 

watering-pot  fistula,  403. 
Gosselin,  fissure  in  ano,  291. 

glandular  papilloma,  738. 

stricture,  470. 

third  sphincter,  20. 
Gowers,  physiology,  44. 
Goyraud,  malformations,  71. 
Green,  tubercular  ulcerations  of  rectum  and 

sigmoid,  209. 
GrefErath,  fistula,  359. 

tuberculosis  of  the  rectum,  360. 
Grenet,  sarcoma,  805. 
Gross,  hspinorrhoids,  635. 

malformations,  91. 

recto-eolonic  alimentation,  930. 
Grutzner,   recto-colonic  alimentation,  9.32. 
Gumma,  244. 

anal,  244. 

distinguished  from  enlarged  glands,  246. 

in  congenital  syphilis,  254. 

in  recto-genital  sseptum,  244. 

in  stricture,  475. 

obstruction  of  rectum  from,  246. 

rectal,  244. 
Guyon,    treatment    of    multiple    adenoma, 
735. 

Hsemorrhage,  rectal,  .336. 

concealed,  resembling  abscess,  356. 

following  operations  under  cocaine,  410. 

from  foreign  bodies  in  rectum,  904. 

in  fistula,  409. 
Haemorrhoids,  582. 

abscess  after  operation,  664. 

accidental,  592. 

accidents  after  injection,  628. 

accidents    and    complications    following 
operation,  650,  660. 

after-treatment  in  clamp-and-cautery  op- 
eration, 644. 

age,  583. 

Allingham's  operation,  633. 

American  operation,  6.58. 

ana'sthetics,  631. 

anatomical  causes,  586. 

arterial,  593,  607. 

bleeding,  592. 

blind,  592. 

causes,  583. 

climatic,  586. 


Haemorrhoids,  capillary,  593,  610. 
cauterization  of,  621. 
clamp  and  cautery,  637. 
columnar,  605. 
compound,  592. 
connective  tissue,  593,  60.3. 
constipation  as  cause  of,  587. 
constitutional,  593. 
crushing  operation,  645. 
cutaneous,  593. 
definition,  582. 
diet,  as  cause  of,  588. 
dilatation  of  sphincter,  618. 
disea.ses  that  cause,  589. 
drugs  as  cause  of,  588. 
dy.suria  following  operation,  661. 
Earle's  operation,  654. 
electrolysis  for,  622. 
etiology,  583. 
excision  of,  648. 
exciting  causes,  587. 
external,  594. 
fistula  after  operation,  664. 
fleshy,  593. 

from  constitutional  diseases,  589. 
habits  as  causes,  influence  of,  584. 
"  ha»morrhois  c»ca,"  592. 
"  ha^morrhois  fluentes  sue  coruenta,"  592. 
heredity  as  cause  of,  585. 
in  catarrhal  diseases,  591. 
inflammatory,  593. 
internal,  .592,  604. 
internal,  treatment  of,  612. 
interno-external,  592. 
itching,  593. 
ligature  in,  631. 
limited  excision,  655. 
Mathews'  method  of  ligation,  632. 
mixed,  592,  611. 
najvoid,  610. 
nomenclature,  592. 
occult,  592. 
open,  592. 
operation  for,  in  connection  with  fistula, 

419. 
operative  treatment,  618. 
pain  following  operation,  661. 
palliative  treatment,  613. 
period   of    confinement    after   operation, 

662. 
pile-pipe,  616. 
predisposing  causes,  583. 
preparation  of  patient  for  operation,  630. 
preventive  treatment,  612. 
recurrences  after  injection,  629. 
secondary   hsemorrhage   after  operation, 

662, 


INDEX 


951 


Haemorrhoids,  sex  as  cause  of,  584. 

solution  for  injection,  627. 

strain  as  a  cause,  589. 

strangulated,  658. 

strangulated,  operation,  659. 

stricture  after  operation,  664. 

submucous  ligature,  636. 

temperament  as  cause  of,  585. 

thrombotic,  .594,  605. 

treatment  by  injection,  622. 

ulceration  after  operation,  665. 

varicose,  external,  597. 

varicose,  internal,  605. 

venous,  59.3. 

white,  593,  609. 

Wliitehead's  operation  for,  648. 
Hahn,  phagedenic  ulceration,  247. 
Hamilton,  hsemorrhoids,  604. 
Samonic,  catarrhal  diseases,  149,  153. 

metastasis  in  sarcoma,  802. 

proliferating  proctitis.  249. 

reetitis  proliferante,  473. 
Harris,  H.  F.,  catarrhal  diseases,  159. 
Harris,  dysenten,-,  164. 
Hartley,  chancre  of  the  rectum,  233. 
Hartmann,  adenoma,  723. 

anatomy,  15. 

ano-rectal  s\-philoma,  249. 

chancre,  228. 

etiological  factors  in   perirectal  abscess, 
324. 

excLsion  of  stricture,  509. 

extension  of  carcinoma,  778. 

extirpation  of  the  rectum,  814. 

fissure,  294,  296. 

horseshoe  fistula,  407. 

hj'perplastic  tuberculosis,  212. 

ischio-rectal  abscess,  337. 

Ij-mphadenoma  of  rectum,  721. 

perirectal  abscesses,  321. 

perirectal  stricture,  466. 

stricture,  472,  474. 

subtegumentan,'  abscess,  .327. 

treatment  of  stricture  by  bougies,  499. 

tubercular  fistula,  356. 

tuberculosis  of  the  rectum,  360. 

verrucous  ulcerations  of  anus,  205. 
Hauser,  papdloma,  739. 
Havershon,  dysenteric  ulceration,  284. 
Hawkins,  foreign  bodies,  901,  903. 
Hegar's   operation  for  extirpation  of  rec- 
tum, 822. 
Heimann,  statistics  of  carcinoma,  761. 
Heitzmann,  multiple  adenoma,  732. 

pol}."pus,  713. 

tegumentarj-  abscess,  326. 
Helmuth's  speciilum,  116. 


Hensing,  intersigmoid  fossa,  41. 
Herczel,  recto-vesical  fi.stula,  439. 
Heredity,  in  carcinoma,  763. 
Hermann,  tubular  glands,  9. 
Hernia,  rectal,  676,  705. 
Herpes,  260. 

pruritus  from,  572. 
Heuck,  heredity  in  carcinoma,  763. 
Heuel,  Franz,  endoscope,  12,  122. 
Heurtaux,  myoma,  720. 
Heydenreich,  recto-vagina!   fistula,   451. 
Hilton,  incision  of  fissure,  314. 

white  line,  9. 
Hindgut,  1,  2,  3. 
Hochenegg,  metastasis  in  carcinoma,  779. 

operation  for  extirpation  of  rectum,  822. 
Holt,  colitis,  187,  188. 
Hood,  foreign  bodies,  906. 
Hotiston,  folds,  17. 

hemorrhoids,  621. 

valves  of  rectum,  24,  28. 
Howse,  colostomy,  887. 
Hubert,  multiple  adenoma,  727. 
Hulke,  m}-xoma,  722. 

Humphreys,  proctotomy  for  stricture,  .503. 
Hunt,  dermoid  cysts,  749. 
Hutchinson,  malformations,  69. 

recto-colonic  alimentation,  934. 
Hydatids,  of  the  rectum,  757. 

of  the  mesorectum,  758. 

of  the  recto-vaginal  saeptum,  758. 
Hj'perplastic  tuberculosis,  211. 
Hj-poblast,  1,  2,  3,  4. 
Hyrtl,  third  sphincter,  20. 
Hysterical  rectum,  922. 

aruEmia  and  nerA'ous  exhaustion,  causing, 
929. 

cn.-pts  of  Morgagni  in,  928. 

displacements  of  uterus,  causing,  928. 

etiolog}-  of,  923. 

thread-like  stricture,  929. 

treatment,  927. 

Impaction,  525,  564. 

sjTnptoms,  564. 

treatment,  565. 
Imperforate  anus,  54. 

colostomy  for,  80. 

statistics  of,  47. 

table  of  mortaUty,  83. 
Incontinence  of  fseces,  412,  413. 

causes,  413. 

frequency  of,  412. 

from  di^■ulsion  of  sphincter,  413. 

from  insensitive  rectum,  926. 

treatment,  414. 
Inflammation  of  rectum.     See  Proctitis. 


952 


THE   ANUS,   RECTUM.   AND  PELVIC   COLON 


Injection  treatment   of  haemorrhoids,  622. 

accidents  from,  628. 

recurrence  after,  629. 
Injuries  of  the  rectum.     See  Wounds. 
Inman,  prolonged  constipation,  518. 
Insensitive  rectum,  926. 
Intersigmoid  fossa,  40. 

Intussusception,  causing  constipation,  541. 
Iodides,  251. 

methods  of  administration,  251. 
Irrigator,  rectal,  Tut  tie's,  144. 
Ischio-coccygeus  muscle,  13. 
Ischio-rectal  abscess,  331. 

arrangement  of,  13. 

functions,  13. 
Itching  piles,  593. 

Jaccoud,  formula  for  recto-colonic  ahraen- 

t  at  ion,  9.36. 
Jacob's  ulcer,  263. 
Jacoby,  relations  of  sigmoid,  42. 
Jardine,  dermoid  cysts,  748. 
Jeannel,  cicatricial  stricture,  465. 

inguinal  colostomy,  875. 

prolapse  of  rectum,  695. 
Jeffries,  F.  M.,  colitis,  189. 

fiscal  examinations,   131. 

stricture,  pathology,  472,  476. 
Jensen,  hydatids,  757. 
Jessett,  carcinoma,  761. 
Johnston,  intussusception,  541. 
Jones,  dysentery,  159. 
Jonnesco,  retro-rectal  space.s,  36. 

sigmoid,  39. 

superior  pelvi-rectal  spaces,  36. 
Jordan,  idiopathic  gangrenous  periproctitis, 

350. 
Jullien,  chancre,  228. 

venereal  diseases,  218. 

Kaemm,  adenoma  of  rectum,  723. 
Kammerer,  colostomy  for  stricture,  513. 
Kartulis,  dysentery,  159. 
Kelly,   Howard,   abdominal  extirpation  of 
the  rectum,  838. 

apparatus   for  knee-chest   posture,    104, 
114. 

scoop,  126. 

tubes,  117,  121. 
Kelsey,  catarrhal  diseases,  142. 

dysenteric  stricture,  481. 

dysenteric  ulceration,  284. 

idiopathic  gangrenous  periproctitis,  351. 

inguinal  colostomy,  862. 

injection  of  haemorrhoids,  629. 

lupoid  ulceration  of  anus,  203. 

proliferating  proctitis,  249. 


Kelsey,  rectal  hernia,  705. 

speculum,  115. 

subtegumentary  abscess,  327. 

treatment  of  incontinence,  418. 

treatment  of  multiple  adenoma,  737. 

tuberculosis,  200. 
Keuster,  gummata  of  rectum,  244. 
Keyes,  treatment  of  stricture,  498. 
Kidney,  floating,  causing  colitis,  176. 
Kirmisson,  .stricture  from  prostatic  disease, 

467. 
Klebs-Loeffler  Ijacillus,  166. 
Klein,  catarrhal  diseases,  166. 
Koch,  initial  tuberculosis  of  the  rectum,  360. 

perianal  and  perirectal  abscess,  319. 
Koenig,  tubercular  fistula,  356. 
Kohlrausch,  constipation,  535. 

niuscularis  mucosa,  18. 

plica  transversalis  recti,  25. 

tensor  fasciic  pelvis,  13. 
Konig,  extra-rectal  dermoids,  751. 
Kramcria,  aqueous  extract,  preparation  of, 
151. 

Kraske's  operation,  821. 
Krefting,  venereal  diseases,  220. 
Kronlein,  malformations,  79. 

statistics  on  carcinoma,  761. 
Krouse,  cicatricial  stricture,  465. 

proctoplasty,  510. 
Kruse,  dysentery,  159. 
Kussmaul,  diabetic  ulceration,  287. 

Lachowski,  excision  of  stricture,  508. 
Ladinski,  ca.se  of  prolapse,  679. 

rectal  .snare,  715. 
Laflenr,  dysentery,  159. 
Lambert,  dysentery,  159. 
Lambotte,  prolapse  of  rectum,  704. 
Lambotte,  wounds  of  the  rectum,  918. 
Lamier,  longitudinal  muscular  fibers,  22,  28. 
Landel,  papilloma,  738. 
Lane,  phagedenic  ulceration,  247. 
Lange,  operation  for  prolapse  of  rectum,  690. 
Langley,  ner\'e  supply  of  anus  and  rectum, 

.33. 
Lannelongue,  malformations,  84. 

perianal  and  perirectal  abscesses,  321. 
Laparotomy  in  diagnosis  of  cancer,  491. 

diagnosis  of  stricture  in,  491. 

foreign  bodies  for,  912. 
Laplace,  forceps,  880. 
Lapointe,  excision  of  stricture,  509. 
Laroyenne,  foreign  bodies,  907. 
Lartigau,  hyperplastic  tuberculosis,  211. 
Lateral  entero-anastomosis,  883. 
Lauenstein,  operation  for  recto-vaginal  fis- 
tula, 451. 


INDEX 


953 


Lauers,  entero-uterine  fistula,  447. 

Laugier,  rectometer,  491. 

Laws,  proctoscope,  125. 

Layers  of  rectal  walls,  39. 

Le  Dentu,  recto-vaginal  fistula,  452. 

Ledru,  extirpation  of  rectum,  814. 

Lee,  hasmorrhoids,  637. 

Le  Fort,  electrolysis  in  stricture,  501. 

suggestion  in  foreign  bodies,  910. 
Leichtenstem,  carcinoma,  761. 

foreign  bodies  in  the  rectum,  898. 

rectal  malformations,  61. 
Lentz  on  dysentery,  160. 
Leube,  extension  of  carcinoma,  778. 

recto-colonic  alimentation,  930. 
Levator  ani  muscle,  11. 
Levy,  operation,  822. 
Lieberkuhn,  follicles,  18,  45. 
LiefEring,  perianal  ^nd  perirectal  abscesses, 

321. 
Ligament,  Poupart's,  36. 

sacro-ischiatic,   7. 
Ligature,  elastic,  in  fistula,  381. 

in  haemorrhoids,  631. 

submucous,  for  piles,  636. 
Lilienthal,  multiple  adenoma,  732,  736. 
Line,  ano-rectal,  8,  24. 
Line,  Hilton's  white,  9. 
Lipoma,  perineal,  718. 

rectal,  718. 

treatment,  719. 
Lisfranc,  excision  of  stricture,  506. 

extirpation  of  rectum,  810,  814. 
Little,  lounge,  105. 
Littre,  inguinal  colostomy,  866. 
Lounge,  Little's,  105. 
Lowson,  colostomy  in  stricture,  513. 
Ludlow,  rectal  hernia,  705. 
Lumbar  center,  44. 

colostomy,  864. 
Lupoid  ulcer,  200. 
Lupus  exedens,  200,  263. 
Luschka's  gland,  2,  4,  30,  38. 
Lymphadenoma,  721. 
Lymphatics,  34. 
Lymph-paths,  18. 

MacCleod,  method  of  sigmoidopexy,  697. 
Maclaren,  ano-rectal  syphiloma,  248. 

phadegenic  chancroid,  226. 
MacMaster,  treatment  of  stricture  by  bou- 
gies, 499. 
Madelung,  hjTlatids  of  rectum,  758. 
Maisonneuve,  fissure,  306. 
Malassez,  chancre,  228. 

stricture,  472. 
Malformations,  47-93. 
61 


Malformations,  colotomy  for,  80. 

methods  to  determine  position  of  rectum 

in,  72. 
of  anus,  49. 

abnormal  narrowing,  51. 
absence,  49. 

atresia  ani  urethralis,  63. 
uterinte,  67. 
vaginalis,  64. 
vesicalis,  63. 
classical  divisions,  49. 
complete  occlusion,  54. 
complete  occlusion,  treatment,  85. 
partial  occlusion,  53. 
partial  occlusion,  treatment,  85. 
of  rectum,  absence  of,  57. 

arrested  high  up  in  pelvis,  75. 
arrested  in  its  descent,  58. 
communication  with  bladder,   88,   89. 
communication  with  urethra,  63. 
communication  with  uterus,  67,  92. 
communication  with  vagina,  64. 
opening  at  abnormal  position,  86. 
opening  into  some  other  viscus,  61. 
statistics  of,  47. 
proctoplasty  versus  colotomy,  82. 
treatment,  68. 
types,  62. 
Malyn,  malformations,  69. 
Mann,  extirpation  of  rectum,  811,  837. 
Manuel,  extra-rectal  dermoids,  752. 
Marchant,  excision  of  stricture,  506. 
Marchetti,  case  of  foreign  body,  909. 
Marchoux,  catarrhal  diseases,  159,  164. 
Marsh,  angeioma,  228,  755. 
Martin,  chancre,  228. 
malformations,  26,  88. 
tubercular  ulcerations  of  rectum  and  sig- 
moid, 209. 
Martin,  T.  0.,  angeioma,  755. 
atmospheric  pressure,   125. 
chair,   104. 
coactor,  500. 
obturator,  121. 
valves,  28. 
valvotomy,  558. 
Martineau,  chancre  of  the  rectum,  232. 
Martland,  artificial  anus,  867. 
colotomy  for  stricture,  512. 
Mason,  chancroids,  223. 

stricture,  470. 
Massage  of  sphincter,  for  fissure,  306. 
Matas,  malformations,  69. 
Mathews,  stricture,  cause  of  stricture,  480. 
fistulotome,  383. 
haemorrhoids,  635. 
hysterical  n-ctum,  924. 


954 


THE   ANUS,   RECTUM,   AXD   PELVIC  COLON 


Mathews,  incision  of  fissure,  310. 

ligation  of  liamorrlioids,  632. 

prolonged  constipation,  518. 

pruritus  ani,  578. 

rectal  divulsor,  619. 

sigmoidopexy,  697. 

speculum,  116. 
Matienzo,  foreign  bodies,  901. 
Mattei.   chronic  constipation,  547. 
Matterstock,  venereal  diseases,  214. 
MaunseU,  operation  for  extirpation  of  rec- 
tum, 842. 
Maydl,  malformations,  82. 
Maydl-Reclus,  method  in  colostomy,  875. 
McCosh,  myoma  of  rectum,  720. 
McDonald,  Angus,  tuberculosis,  201. 
Medina,  phagedenic  chancre,  232. 
Mercier,  recto-vesical  fistula,  439. 
Mercury  in  rectal  diseases,  243. 
Mesenteron,  60. 
Mesoblast,  1,  2,  3,  4,  60. 
Mesosigmoid,  40. 
Metastasis  in  sarcoma,  802. 

in  carcinoma,  779. 
Metchnikoff,     thrombosis     of     hinphatic 

trunks,  324. 
Mevmier,  sarcoma,  802. 
Meyer,  liydatids,  758. 
Meyer,  Alfred,  tuberculosis  of  the  rectum, 

360. 
Meyer,  Willy,  constipation,  541. 
Mikulicz,  amputation  of  rectum,  699. 
Miles,  internal  fibers  of  the  rectum,  21. 
Miliary  tuberculosis,  193. 
Mixed  sores,  231. 
Modlin,  malformations,  66. 
Molk,  perineal  lipoma,  718. 

sacro-coccygeal  tumors,  754. 
Molliere,  chancroids,  222. 

cicatricial  stricture,  464. 

fissure,  291. 

fungus  recti,  757. 

gumma  of  anus,  244. 

malformations  of  recttun,  59. 
Monod,  retention  of  urine  in  rectum,  441. 
Montgomery,  recto-vaginal  fistula,  452. 
Moran,  foreign  bodies,  899. 
Moreau,  h-mphatics,  36. 

malformations,  47. 
Morel-Lavelles,  chancre,  229. 
Morestin,  nerve  supply  of  anus  and  rectum, 

33. 
Morgagni,  anal  pockets,  24. 

columns  of,  22. 

crj'pts  of,  23. 

imperforate  ani,  48. 

malformations,  66. 


Morgagni,  semilunar  valves,  14,  IS. 

Morning  diarrhtea,  272. 

Morphine  in  shock,  412. 

Morris,  recto-urethral  fistula,  403. 

Mortality,  from  operations  for  imperforate 

anus,  83. 
Mouchet,  h\-perplastic  tuberculosis,  211. 
Moxon,  colitis,   179. 

Mucous  colitis.     See  Membranous  Colitis. 
Mucous  membrane  of  rectum,  2. 

appearance  of,  in  gonorrhoea,  214. 

susceptibility  to  gonorrhtcal  virus,  213. 
Mucous  patches,  235. 
Muller,  catarrhal  diseases,  151. 
Multiple,  adenomata,  725. 

age,  726. 

color,  729. 

conformation,  728. 

consistence,  729. 

diagnosis,  731. 

distribution,  727. 

heredity,  727. 

microscopic  appearance,  732. 

mucous  membrane,  730. 

pathology,  732. 

sex,  726. 

s}-mptoms,  730. 

transfonnation,  733. 

treatment,  734. 
Munde,  recto-vaginal  fistula,  449. 
Murphy,  J.  B.,  button,  880. 

failure  to  recover,  842. 

recto-vaginal  extirpation  of  rectum,  833. 
Murray,  catarrhal  diseases,  160,  165. 
Muscatello,  perirectal  abscesses,  321. 
Muscles,  of  anus  and  rectum,  6. 

accelerator  urina>,  6. 

circulatory  fibers,  19. 

external  sphincter,  10. 

internal  sphincter,  19. 

ischio-coccygeus,  13. 

levator  ani,   11. 

longitudinal  fibers,  21. 

recto-coccygeus,  13. 

third  .sphincter,  20. 

transversus  perinaei,  6. 
Muscularis  mucosa,  18. 
Musilier,  recto-uterine  fistula, 
Myoma  of  rectum,  720. 
Mj^oma,  447,  722. 

Nse\-us  of  rectum,  755. 

Nedham,  case  of  prolapse,  709. 

Needle-holder,  387. 

Neisser,  venereal  diseases,  213,  214 

Nelaton,  third  sphincter,  20. 

Neoplastic  stricture,  459. 


INDEX 


955 


Nerve,  sphincterian,  34. 

centers  of  rectum,  44. 
Nerves  of  anus  and  rectum,  34. 

of  sigmoid,  42. 
Nervous  rectum,  924. 

faecal  concretions  in,  924. 

inflammation  of  crypts  in,  924. 

insensitiveness  of,  926. 

rheumatism  and  gout  in,  926. 

treatment,  927. 
Neumann,  chancre,  229. 

electrolysis  on  stricture,  501. 
Newsholme,  carcinoma,  760. 
Nivet,  chancre,  228. 
Nordmann,  wounds  of  rectum,  916. 
Norton,  extirpation  of  rectum,  832. 
Nothnagel,  hyperplasia  of  colon,  536. 
Nutrient  enemata.     See  Recto-colonic   Ali- 
mentation, 930. 

O'Beirne,  defecation,  45. 

rectal  valves,  25. 

third  sphincter,  20. 
Obre,  hydatids,  758. 
Obscure  diseases  of  the  rectum,  922. 

Curling  on,  922. 
Obstipation,  517. 

definition,  525. 

malformations  causing,  533. 
Obturator,  Martin's,  121. 
Occlusion  of  anus,  85. 
O'Hara,  intestinal  clamp,  881. 

method  of  entero-anastomosis,  883. 
Ohmann-Dumesnil,  chancre  of  rectum,  233. 
Ombredanne,  pelvi-rectal  spaces  of  rectum, 
36. 

recto-rectal  spaces  of  rectum,  36. 
Omega  loop,  39. 
Omerod,  colitis,  182. 
O'Neill,  speculum,  115. 
Osteosarcoma,  422. 

fistula  from,  422. 
Otis,  rectal  veins,  25,  30. 
Otis,  F.  N.,  venereal  diseases,  213. 

Page,  extra-rectal  dermoids,  752. 

Paget,  cutaneous  growths  about  the  anus, 

239. 
Pailhes,  abnormal  narrowing  of  anus,  21. 
Palpation,  examination  by,  106. 
Panas,  stricture,  472. 
PapillsR,  anal,  9. 

hypertrophied  anal,  758. 
symptoms  of,  759. 
treatment,  759. 
Papilloma,  738. 

complications  of,  739. 


Papilloma,  constipation  causing,  742. 
constitutional  symptoms  of,  743. 
development,  741. 
diagnosis,  744. 
dimensions,  739. 
etiology,  741. 
form,  739. 
frequency,  738. 
glandular,  738. 
haemorrhages,  742. 
histology,  740. 

macroscopic  characteristics,  739. 
methods  of  ligature,  746. 
microscopic  characteristics,  740. 
mucous  membrane,  743. 
pain,  743. 

physical  symptoms,  743. 
premonitory  S3Tnptoms,  741. 
protrusion,  743. 

resemblance  to  epithelioma,  740. 
spontaneous  elimination,  745. 
symptoms,  742. 
transformation,  745. 
treatment,  745. 
Pappendorf,  absence  of  anus,  58. 

malformations,  49. 
Paquelin,  cautery,  639. 
Parasites,  133. 

classification  of,  133. 
Parke,  carcinoma,  760. 
Paschal,  dysentery,  159. 
Pasteau,  extension  of  carcinoma,  778. 
Paul,  sarcoma,  808. 
Peacock,  sloughing  of  rectum,  704. 
Pean,  chancres,  228. 
Pearls,  cancer,  767. 
"Pecten,"  3,  4. 

Pelliet,  hyperplastic  tuberculosis,  212. 
Pelvic  colon,  41,  42. 
definition,  1. 
direction,  39. 
divisions,  39. 
relations,  42. 
tuberculosis,  193. 
Pelvis,  divisions  of,  4. 
Pennington,  anatomy  of  valves,  26,  28. 
clip,  560. 

hypertrophied  valves,  535. 
proctoscope,   122. 
tube,  643. 
Perinseum,  5. 
Perineal  body,  6. 

rhaphe,  8. 
Periproctitis,  endocarditis,  and  pericarditis, 
349. 
diffuse  septic,  348. 
etiology,  348. 


956 


THE   ANUS,   RECTUM,   AND   PELVIC   COLON 


Periproctitis,  s\Tnptoms,  349. 
treatment,  350. 

idiopathic  gangrenous,  350. 
etiology,  351. 
s.\Tnptomp,  351. 
treatment,  352. 
Perirectal  abscess  from  appendicitis,  340. 
Peristalsis,  reverse,  523. 
Peters,  operation  for  prolapse,  690. 
Peterson,  sarcoma,  801. 
Peterson,  Frederick,  case,  548. 
Petit,  entero-uterine  fistula,  446. 
Phageda?na  in  chancre,  231. 

in  chancroid,  224. 
Phantom  stricture,  468. 
Physiology  of  anus  and  rectum,  43. 
Pierra,  foreign  bodies,  902. 
Piffard,  eczema,  262. 

lupoid  ulceration  of  anus,  204. 
Pile-pipe,  616. 
Piles.     See  Haemorrhoids. 

sentinel,  292. 
Pillars  of  Glisson,  22. 
Pillore,  inguinal  anus,  867. 
Pinault,  excision  of  stricture,  506. 

extirpation  of  rectum,  810. 
"  Plaque  porcelainique,"  236. 
Plexus,  IjTiiphatic,  hj'pogastric,  35. 

inguinal,  35. 

sacral,  35. 
Pockels,  rectal  hernia,  706. 
Pockets,   anal,  23. 
Poelchen,  gummata  of  rectum,  244. 
Pollock,  haemorrhoids,  645. 
PoUoson,  colostomy,  860. 
Polypus,  711. 

development,  712. 

diagnosis,  714. 

histological  tjTpes,  712. 

seat  of,  712. 

section,  713. 

symptoms,  713. 

treatment,  715. 
Port,  dermoid  cysts,  748. 
Pospellow,  chancre,  229. 
Postanal  dimples,  752. 

hairs  in,  752. 

treatnient,  753. 
Posture,  101. 

exaggerated  lithotomy,  103. 

knee-chest,  102. 

Martin,  104. 

Sims,  100. 
Pouch,  recto-vesical,  38. 
Poulet,  foreign  bodies,  898. 

laparotomy  for  foreign  bodies,  913. 
Poupart's  ligament,  36. 


Powell,  prolapse  of  rectum,  681. 

Pratt,  retractor,  116. 

Price,   vaginal   extirpation  of   the  rectum, 

832. 
Prideaux,  simple  cysts,  747. 
Pring,  artificial  anus,  867. 
Prior,  spirillum,  136. 
Probes,  126. 

Procidentia  intestini  recti,  667,  672. 
Proctitis,  139-166. 
acute  catarrhal,  141. 
treatment  of,  144. 
causes  of,  139. 
chronic,  146. 

atrophic,  etiologj',  153. 
s^^nptoms,  153. 
treatment,  1.55. 
hj'pertrophic,  etiology,  147. 
sjTaptoms,  148. 
treatment,  149. 
diphtheritic,  166. 
dysenteric,  158. 
gonorrhceal,  213. 
proliferating,  249. 
Proctocace,  351. 
Proctodeeum,  3. 
Proctoplasty  for  stricture,  509. 

verstts  colotomy,  82-84. 
Protoscope.  Kelly's,  117. 
Laws's,  122. 
Pennington's,  122. 
pneumatic,  123,  490. 
Tuttle's  pneumatic,  123. 
Proctoscopes,  122,  125. 
Proctoscopy,  pneumatic,  121. 
Proctotomy,  502. 
complete,  503. 
internal,  502. 
partial,  502. 
Prolapse  of  rectimi,  667. 
age,  703. 

AUingham  on,  686. 
amputation,  698. 
causing  constipation,  541. 
colopexy,  696. 
complete,  672. 
degrees  of,  673. 
etiology,  678. 
pathology,  679. 
sj-mptoms,  675,  677. 
treatment,  680. 
complications,  of ,  701. 
Delorme's  operation,  688. 
Dieffenbach-Roberts  operation,  689. 
Duret's  operation,  688. 
exci.sion  of,  698,  703. 
haemorrhages  from,  702. 


INDEX 


957 


Prolapse,  hernia,  705. 

incomplete,  667. 
etiology,  668. 
symptoms,  669. 
treatment,  670. 

inflammation  of,  702. 

Lange's  operation,  690. 

partial,  667. 

Peters's  operation,  690. 

rectopexy  for,  691. 

reduction  of,  683. 

rupture  of  hernia  sac,  708. 

sigmoidopexy,  695. 

sloughing  in,  683. 

strangulation  of,  702. 

strangury  from,  683. 

treatment,  670,  685. 

Van  Buren's  operation,  686. 

Verneuil's  operation,  690. 
Prolapsus  recti,  667. 
Pruritus  ani,  568. 

characteristics,  570. 

constitutional  causes,  574. 

eczema,   572. 

essentials,  568. 

etiology,  571. 

external  causes,  571. 

gout,  574. 

herpes,  572. 

idiosyncrasies,  573. 

local  causes,  572. 

parasites,  571. 

pressure,  580. 

reflex  causes,  575. 

rheumatism,  574. 

symptoms,  570. 

treatment,  575. 

constitutional,  577. 
local,  577. 
operative,  580. 

uricsemia,  causing,  574. 

venereal  diseases,  causing,  573. 
Pulitzer,  chronic  constipation,  547. 
Pye-Smyth,  colitis,  180. 

Quain,  villous  tumors,  738. 
Quenu  and  Hartmann,   abdomino-perineal 
extirpation  of  the  rectum,  848. 

adenoma,  723. 

anatomy,  15. 

anorectal  syphiloma,  249. 

catarrhal  diseases,  149,  153. 

chancre,  228. 

constipation,  535. 

etiological  factors  in  perirectal  abscesses, 
324. 

excision  of  stricture,  506,  509. 


Quenu  and  Hartmann,  extension  of  carci- 
noma, 778. 
fissure,  294. 
horseshoe  fistula,  407. 
lupoid  ulceration  of  anus,  203. 
lymphadenoma  of  rectum,  721. 
lymphatics,  34. 
papilloma,  738. 

perineal  extirpation  of  rectum,   817. 
repair  of  abscess,  358. 
treatment  of  stricture,  499. 
tuberculosis,  198. 
veins  of  the  rectum,  31. 
verrucous  ulcerations  of  anus,  205. 

Rabe,  carcinoma,  778. 

Ratjen,  formula  for  recto-colonic  alimenta- 
tion, 937. 
Ray  fungus,  757. 
Recamier,  fissure,  306. 
Rectitis  proliferante,  473. 

syphilitique,  249. 
Rectocele,  congenital,  4. 
Recto-colonic  alimentation,  930. 

Boas's  formula,  934. 

defibrinized  blood,  933. 

eggs,  932. 

glucose,  932. 

indications  for,  931. 

method  of  administering,  934. 

milk,  932. 

organo  serum,  933. 

proteids,  932. 

reverse  peristalsis,  932. 

Schlesinger's  formula,  937. 

Singer's  formula,  937. 
Rectometer,  491. 
Rectopexy,  for  prolapse,  691. 
Rectophobia,  610. 
Rectorrhaphj',  688. 
Rectum,  1. 

abnormalities  of,  47  et  seq. 
treatment  of,  86-93. 

absence  of,  57. 

absorptive  action  of,  45. 

amputation  of,  698. 
Fowler's  method,  700. 
Mikulicz's  method,  699. 

anatomical  stricture,  17. 

arrested  in  pelvis,  75-79. 

as  place  for  concealment,  900. 

atony,  16. 

ballooning,  118. 

catarrhal  diseases,  139-166. 

chancre,  323. 

chancroid,  223. 

circular  fibers,  19. 


958 


THE   ANUS,   RECTUM,    AND   PELVIC  COLON 


Rectum,  columns  of,  22. 

communicating  with  other  organs,  88  ct 

seq. 
conformation,  15. 
course  and  direction,  14. 
development,  4. 
dimensions,  15. 
divisions,  14. 
epithelial  layer,  18. 
examination  of,  digital,  107,  110. 

instrumental,  113-131. 

manual,  110-113. 

ocular,  126. 
external  surface,  17. 
extirpation  of,  810. 
functions,  45. 
fungus,  757. 
gonorrhcea  of,  214. 
gumma  of,  244. 
hernia  of,  705. 
hydatids  of,  757. 
hysterical,  922. 
intraperitoneal  portion,  15. 
insane,  922. 
insensitive,  926. 
irrigator  for,  144. 

longitudinal  muscular  layer,  20,  27. 
malformations,  82. 
mucous  niembrane,  17,  18. 
mucous  patches  in,  2S6,  472. 
muscles,  19. 
neoplasms,  benign,  711. 

malignant,  760. 
nerve  affections  in,  926. 
nerve  supply,  33. 
nervous,  922. 
neuralgia  of,  922. 
obscure  diseases  of,  922. 
peritoneal  portion,  15. 
physiology,  43. 
prolapse,  667. 
reflex  irritations,  925. 
relations,  37. 
rudimentary,  2. 
rupture,  916. 
serous  coat,  22. 
small  red  papules,  237. 
spinal  nerves,  34. 
stricture  of,  455. 
submucous  layer,  19. 
supports  of,  38. 
syphilis  of,  228. 
tuberculosis  of,  192,  206. 
ulcerations,  266. 

carcinomatous,  285. 

catarrhal,  275. 

diabetic,  287. 


Rectum,  ulcerations,  dysenteric,  284. 

follicular,  280. 

luemorrlioidal,  278. 

hepatic,  288. 

niarasmic,  289. 

nephritic,  285. 

primary,  228. 

secondary,  237. 

strictural,  282. 

syphilitic,  237,  238. 

tertiary,  247. 

traumatic,  273. 

trophic,  288. 

varicose,  275. 
valves  of,  26. 

semilunar,  23. 
vascular  supply,  29. 
veins,  30. 
wounds,  915. 
Rehn,  extirpation  of  the  rectum,  832. 
Rehn-Rydygier,  operation,  822. 
Renauldin,  constipation,  535. 
Retractors,  388. 
Retractors,  recti,  13. 
Retzius,  space  of,  .36. 
Reverdin,  extirpation  of  the  rectum,  840. 
"  Rliagades,"  238. 
Richet,  recto-urethral  fistula,  429. 
treatment  of  multiple  adenoma,  735. 
white  haemorrhoids,  593. 
Richevaud,  syphilitic  stricture,  470. 
Ricketts,  luemorrhoids,  636. 
Ricord,  malformations,  66. 
Rieder,   pathology   of  syphilitic    stricture, 

478. 
Riegl,   formula  for  recto-colonic  alimenta- 
tion, 936. 
Rinne,  metastasis  in  carcinoma,  779. 
Rizzoli,  malformations,  91. 
Roberts,  lipoma  of  rectum,  718. 
Robinson,  dermoid  cysts,  750. 

rodent  ulcer,  264. 
Rodent  ulcers,  263. 
Roecke,  sarcoma,  800. 
Roentgen  rays,  198. 
Rogers,  dysentery,  162. 
Rokitansky,  villous  cancer,  738. 
RoUeston,  tubercular  stricture,  480. 
Rollet,  phagedenic  chancroid,  213,  224. 
Rose,  extirpation  of  rectum,  822. 

recto-vaginal  fistula,  454. 
Rosenheim,  enteroptosis,  536. 
Roser,  catarrhal  diseases,  142. 

intersigmoid  fossa,  41. 
Rotter,  nndtiple  adenoma,  732. 
Routier,  extirpation  of  rectum,  814. 
verrucous  ulceration  of  anus,  205. 


INDEX 


959 


Roux,  hydatid?,  758. 
malformations,  70. 
Rydygier,  incontinence  after  extirpation  of 
rectum,  856. 

Sabine,  manual  exploration.  111. 

Salsotto,  chancre,  228. 

Sands,  haemorrhoids,  6.3.5. 

Sands,  H.  B.,  manual  exploration,  111. 

Sappey,  anatom}',  15,  20. 

Sarcoma,  800. 

age,  805. 

alveolar,  802. 

blood-vessfas,  803. 

capsule,  803. 

color,  801. 

consistence,  801. 

course  of.  801. 

diagnosis,  807. 

etiology,  804. 

extension,  803. 

form,  800. 

general  sjTnptoms,  807. 

histology,  802. 

melanosis,  804. 

metastasis,  802. 

mixed,  802. 

number,  800. 

odor,  806. 

pain,  807. 

polypoid,  802. 

prognosis,  808. 

protrusion,  806. 

round-cell,  802. 

sarco-coccygeal,  754. 

sex,  805. 

site,  801. 

spindle-cell,  802. 

state  of  bowels,  807. 

symptoms,  805. 

treatment,  808. 

types,  802. 

■wide  distribution,  807. 
Schafier,  embryology,  2,  18. 
Schauta,  recto-vaginal  fistula,  452. 
Schede,  colostomy,  812,  860. 
Schelky,  extirpation  of  rectum,  814. 
Schenck,  malformations,  58. 
Schifferdecker,  the  sigmoid,  39. 
Schlesinger,  formula  for  recto-colonic  ali- 
mentation, 937. 
Schmey,  prolapse  of  rectum,  679. 
Schoening,  extension  of  carcinoma,  778. 
Schuchardt,  lupoid  ulceration  of  anus,  202. 
Schuh,  meta.stasis  in  carcinoma,  779. 
Scirrhus,  atrophic,  771. 
Scissors,  rectal  specimen,  781. 


Scoop,  Kelly's,  119,  127. 

rectal,  126. 

Tuttle's,  126. 
SediUot,  malformations,  47. 
Senn,  bone-plates,  880. 

extirpation  of  rectum,  822. 

myoma  of  rectum,  720. 
SepsLs  from  fistula,  412. 

in  extirpation  of  rectum,  788. 
Serremone,  congenital  narro^^ing  of  anus, 

.52. 
Shiga,  bacUlus  of,  158. 
Shuford's  solution,  627. 
Shuldham,  venereal  diseases,  217 
Sick,  chancre,  228. 

venereal  diseases,  219. 
Sigmoid  flexure,  1,  39. 

absorptive  action  of,  45. 

acute  flexures,  537. 

anatomy,  39. 

blood-supply,  42. 

catarrhal  diseases,  139,  166. 

course,  14. 

development,  1. 

direction,  39. 

di^■isions,  39. 

extent,  1. 

functions,  45. 

mesenterj',  40. 

mucous  layer,  40. 

nerves,  42. 

physiology-,  43. 

relations,  42. 

serous  layer,  40. 

submucous  layer,  39. 

tuberculosis,  206. 

ulcerations,  266. 

waUs,  39. 
Sigmoiditis,  139,  166. 

cause,  139. 

chronic,  146. 

dysenteric,  158. 
Sigmoidopexy,  69-5. 

MacCleod's  method,  697. 

Mathews'  case  of,  697. 
Sigmoidoscope,  author's  eur\-ed,  121. 

author's  pneumatic,  124. 

KeUy's,  121. 

Laws's,   123. 
Simmons,  perianal  abscesses,  320. 

perirectal  absce.=«es,  320. 
Simms,  wounds  and  injuries  of  the  rectum, 
917. 

atmospheric    ballooning    of   the    rectum, 
167. 
Simon,  manual  exploration,  110. 

recto-vaginal  fistula,  454. 


960 


THE   ANUS,   RECTUM,    AND   PELVIC  COLON 


Singer,  formula  for  recto-colonic  alimenta- 
tion, 937. 
Sinus,  sacro-coccygeal,  751. 
Skene,  entero-vcsical  fistula,  446. 
Sklifasowski,  multiple  adenoma,  732. 
Smith,  lutmorrhoids,  637. 

hsemorrhoidal  crusher,  647. 

perirectal  stricture,  468. 
Smith,  Henry,  extirpation  of  rectum,  812. 

prolapse  of  rectum,  687. 
Smith,  Stephen,  excision  of  fistula,  391. 
Smith,  Thomas,  treatment  of  multiple  ad- 
enoma, 736. 
Snare,  Ladinski's  rectal,  715. 
Sormanani,  perianal  abscesses,  319. 

perirectal  abscesses,  319. 
Sounds,  12S. 
Sourdille,  hyperplastic  tuberculosis,  211. 

stricture,  472. 
Space,  ischio-rectal,  6. 

prevesical,  of  Retzius,  36. 

retro-rectal,  7,  36. 

superior  pehi-rectal,  7,  36. 
Specula,  114-118. 

Allingham's,  118. 

Andrews's  tubular,  116. 

Bodenhamer's  tubular,  116. 

Brinckerhoff's,  115. 

conical  bivalve,  114. 

Cook's  tubular,  117. 

Ferguson's  tubular,  116. 

Gant's,  115. 

Helmuth's,   116. 

Kelly's,  117. 

Kelsey's,  115. 

Mathews'  self-retaining,  116. 

O'Xeill's,  115. 

Sims's  vaginal,  116. 

Tuttle's  conical  fenestrated,  115. 

Van  Buren's,  116. 
Sphincter,  digital  dilatation,  for  fissure,  306. 

dilator,  Kelly's,  120. 

internal,  19,  20. 

spasm  of,  in  constipation,  538,  556. 
SphincteropcB  i^,  887. 
Spina  bifida,  anterior,  755. 
Sponge-holder,  127. 
Stafford,  proctotomy  for  stricture,  502. 
Staphylococcus,  136. 
Starr,  malformations,  47. 
Statistics  of  operation  for  carcinoma  of  rec- 
tum, 786,  787. 

of  extirpation  of  rectum,  857. 

inguinal  colostomy,  S62. 

injection  treatment  of  piles,  623.     ' 
Stengel,  m>-xoma,  722. 
Stierlin,  hereditj-  in  carcinoma,  763. 


Stille,  .\lfred,  catarrhal  diseases,  163. 
Stoltz,  adenoma  of  the  rectum,  723. 
Stone,  foreign  bodies,  907. 
Stone  in  bladder,  541. 
Streptococcus,   136. 
Stricture  of  rectmn,  455. 

after  operation  for  hsemorrhoids,  664. 

annular,  455. 

cauterization,  501. 

cicatricial,  464. 

classification,  455. 

colostomy,  512. 

congenital,  458. 

danger  of  dilating,  500. 

diagnosis,  486. 

diagnosis  by  laparotomy,  491. 

diarrhoea,  495. 

diet,  494. 

diffu.se  inflainmatory,  463. 

digital  examination,  488. 

dilatation  of,  496. 

discharge  from,  485. 

divulsion,  500. 

due  to  constipation,  481. 

gunshot  wounds,  481. 

injections,  481. 

pederasty,  481. 
dysuria,  482. 
electrolysis,  501. 
etiology,  479. 
examination,  487. 
excision,  506. 

perineal,  507. 

results  of,  508. 

sacral,  507. 
following  fissure,  317. 
from  prostatic  disease,  467. 
gummata,  475. 
inflammatory,  463,  478. 
inflammatory  stage,  482. 
large  caliber  of,  456. 
laparotomy,  diagnosis  by,  491. 
latent  period,  481. 
lateral  entero-anastomosis,  510. 
local  treatment,  496. 
location,  463. 
malignant,  492. 
medical  treatment,  494. 
method  of  development,  251. 
neoplastic,  459. 
non-malignant,  492. 
obstruction  in,  495. 
obstructive  period,  483. 
odor  of  discharges,  487. 
operative  treatment,  496. 
pathology,  472,  478. 
perirectal,  465. 


INDEX 


961 


Stricture  of  rectum,  phantom,  468. 
proctoplastj',  503,  509. 
proctotomy,  502. 
raclage,  501. 
rapid  dilatation,  500. 
recurrence,  505,  516. 
retained  bougies,  498. 
sex,  479. 
skin-tabs,  485. 
spasmodic,  460. 
symptoms,  481. 
sj-philitic,  2.50,  470,  478. 
pathology',  478. 
sjTnpt-oms,  493. 
tents,  499. 
traumatic,  493. 
treatment,  493. 

bj'  bougies,  496. 
tubercular,  469,  478,  480. 
pathologj',  475,  478. 
symptoms,  493. 
ulcerative  stage,  482. 
vagino-rectal  examination,  489. 
varieties  of,  455. 
Strong,  prolonged  constipation,  518. 

on  dysentery',  163. 
Stroud,  anatomy,  3,  9. 
Sustentator  tunicse  mucosse,  18. 
Sutton,  embn."ological  tumors,  753. 
Swartz,  proctoplasty,  510. 
Swinburne,  tegument  ary  abscess,  326. 
SjTDhilis  of  rectum,  228. 
anal  ulcerations,  238. 
artificial  anus,  253. 
complicated  by  other  diseases,  247. 
congenital,  253. 
early  rectal  ulceration,  239. 
fistvila,  361. 
gimamata,  244. 
hereditary,  253. 
initial  lesion,  228. 
mucous  patches,  235. 
obscure  cases,  241. 
proliferating  proctitis,  249. 
rectal  ulceration,  238. 
secondary  lesions,  235. 
secondary  ulcerative  lesions,  237. 
small  red  papules,  237. 
sources  of  infection,  230. 
tertiary  lesions,  243. 
treatment  of,  241,  251. 
Sj'philoma,  ano-rectal,  248. 
SjTinge,  to  inject  piles,  628. 

Tait,  malformations.  81. 
Tanchard,  adenoma  of  rectum,  723. 
Tanchou,  cicatricial  stricture,  465. 


Tardieu,  venereal  diseases,  213. 
Targett,  colitis,  180. 

trophic  ulceration,  288. 
Taxnier,  rectometer,  491. 
Tamowski,  syphilis  of  rectima,  238. 
Taylor,  curettage  in  cancer,  813. 
Taylor,  R.  W.,  gumma  of  rectvun,  244, 

lupoid  ulceration  of  anus,  203. 

tuberculosis  of  rectxim,  201. 
Tedenat,  lipoma,  718. 

myoma,  720. 
Tenacula,  127,  388. 
Tensor,  fascia?  pehas,  13. 
Terrier,  entero-vesical  fistiila,  446. 

recto-A'aginal  fistula,  451. 
Testut,  anatomj-,  3,  8,  18,  20,  23,  25,  33,  39. 
Thien,  colotomy  for  stricture,  513. 
Thomas,  sloughing  of  rectima,  704. 
Thomas,  T.  G.,  constipation,  541,  547. 
Thompson,  recto-urethral  fistula,  430. 
Thompson,  W.  H.,  cohtis,  167,  186. 
Thompson,  W.  K.,  colitis,  186. 
Thomdike,  laparotom}-  for   foreign  bodies, 

912. 
Tillaux,  foreign  bodies,  907. 
Tormina  ventosa,  287. 
Toupet,  stricture,  472,  474. 

verrucous  ulceration  of  anus,  205. 
Toumier,   recto-colonic   alimentation,   930, 

936. 
Transversus  peringei  muscle,  6. 
Treatment,    operative,    secondary'   hsemor- 
rhage,  662. 

abscess  following,  664. 

erT.'sipelas  following,  663. 
Treitz,  anatomy,  18,  23. 
Trelat,  chancre  of  rectum,  233. 

di^-ulsion  of  stricture,  501. 
Treves,  anatomy,  14,  39. 
Triangle,  rectal,  4. 

urogenital,  4. 
Trousseau,  catarrhal  diseases,  166. 
Trull,  foreign  bodies,  913. 
Tubercular  stricture,  469. 
Tuberculosis,  193. 

anal,  196. 

pathology-,  198. 
treatment,  199. 

cause  of  stricture,  480. 

hj-perplastic,  211. 

of  peh-ic  colon,  206,  209. 

of  rectvun,  206. 

histological  examinations,  207. 
primarj^,  360. 
secondary-,  207. 

.     statistics,  206. 
sjTaptoms,  209. 


962 


THE  AXUS,   RECTUM,   AND   PELVIC  COLON 


Tuberculosis  of  rectum,  trcatmenl,  211. 

perianal,  193. 
TuflBer,  sarcoma,  801. 
Tumors,  benign,  711. 

connective-tissue  type,  711. 

epithelial  type,  711. 

malignant,  760. 
carcinoma,  760. 
sarcoma,  800. 

muscular  type,  711. 

papillary,  738. 

sacro-coccygeal,  753. 
Tumey,  foreign  bodies,  906. 
Tuttle,  ha>morrhoidal  forceps,  638. 

probe,  126. 

rectal  irrigator,  144. 

rectal  spoon,  126. 

sigmoidoscope,  124. 

technique  for  temporary  inguinal  colos- 
tomy, 877. 

Ulcer,  263. 

hitolerable,  291. 
irritable,  291. 
Jacob's,  263. 
rodent,  263. 
Ulceration,  perianal,  traumatic,  258. 
Ulcerations,  258. 

of  anus,  tubercular,  198, 
eczematous,  261. 
gonorrhceal,  216. 
herpetic,  260. 
of  anal  canal,  264. 

distinguished  from  fissure,  265. 
of  peh-ic  colon,  207,  266. 
of  rectum,  266. 

anatomical  causes,  269. 

bacteria,  268. 

carcinomatous,  285. 

catarrhal,  275. 

crypts  of  Morgagni  in,  271. 

diabetic,  287. 

dysenteric,  284. 

etiology,  267. 

exciting  cau.ses,  271. 

follicular,  280. 

from  Bright 's  disease,  285. 

general  symptoms,  271. 

harnorrhoidal,  279. 

hepatic,  288. 

incontinence  of  faeces,  273. 

marasmic,  289. 

morning  diarrlnea,  272. 

non-specific,  258. 

pain,  272. 

predisposing  causes,  268. 

simple,  266. 

specific,  267. 


L'lrcrations  of  rectum,  strict ural,  282, 
symptoms,  271. 
syphilitic,  247. 
systemic,  266. 
tertiary,  247. 
traumatic,  273. 
treatment,  280. 
trophic,  288. 
tubercular,  207. 
varicose,  275. 
verrucous,  204. 
perianal,  258. 
Ureter,  92. 

communicating  with  rectum,  92. 
transplantation  into  the  rectum,  446. 
Urethra,  communicating  with  rectum,  89. 

diseases  of,  in  relation  to  rectum,  451. 
Urine,  retention  of,  in  rectum,  441. 
Uterus,  communication  with  rectum,  92. 

Vagina,  opening  into  rectum,  92. 

rectum  opening  into,  89. 
Valentine,  prolonged  constipation,  518. 
Valtat,  stricture,  472. 
Valves,  Bauhinian,  536. 

rectal,  24,  25,  26. 

cause  of  constipation,  533. 
function,  28. 
Houston's,  20,  21,  24. 
hj'pertrophied,  535. 

semilunar,  23. 
Valvotomy,  in  constipation,  534. 

the  operation,  558. 
Valvular  colostomy,  192. 
Van  Buren,  chancroids,  213,  223. 

enchoiidroma  of  rectum,  717. 

extirpation  of  rectum,  791. 

ha?morrhoids,  635. 

operation  for  prolapse,  686. 

spasmodic  stricture,  460. 

speculum,  116. 
Van  Duyse,  dermoid  cy.sts,  749. 
Van  Harlingen,  ano-reetal  syphiloma,  248. 
Van  Hook,  wounds  of  rectum,  917. 
Vauclaire,  malformations,  84. 
Vaughan,  bacilli  in  perirectal  abscesses,  320. 
Vautrin,  vaginal  extirpation  of  rectum,  832. 
Veins  of  rectum,  30. 

external  hspmorrhoidal,  33. 

internal  ha^morrhoidal,  33. 

middle  hsemorrhoidal,  33. 
Veins  of  sigmoid,  42. 
Velpeau,  third  sphincter,  20. 

extirpation  of  rectum,  814. 

recto-vesical  fistula,  438. 
Vermiform  appendix,  2. 
Vemeuil,  extirpation  of  rectum,  810,  814. 

gumma  of  anus,  244. 


IXDEX 


963 


Verneuil,  hsemorrhoids,  587. 

malformations,  70. 

operation  for  prolapse,  690. 

theory  of  rectal  veins,  32. 
Verruca,  755. 
Veslin,  chancre,  229. 
Vidal  de  Cassis,  chancre  of  rectum,  233. 
Vigne,  fistula,  359. 
Villard,  hj-datids  of  rectmn,  758. 
Villous  tumor,  738. 
Vincent,  malformations,   74,  77. 
Viola  tricolor  in  eczema,  262. 
Virchow,  colitis,  179. 

folhcular  ulceration,  282. 

lipoma  of  rectum,  718. 

multiple  adenoma,  726. 

papilloma,  738. 
Voillemier,  malformations,  59,  86. 
Voit,  recto-colonic  alimentation,  931. 
Von  Hacker,  colostomy,  887. 

foreign  bodies  in  the  rectum,  897. 
Von  Heinecke,  operation  for  extirpation  of 

rectum,  822. 
Von  Jaksch,  parasites,  133. 

perirectal  abscesses,  320. 
Von  Noorden,  diet  in  colitis,  177. 
Voss,  hpoma  of  the  rectum,  718. 

Waldeyer,  anatomy,  3. 

Wales,  bougie,  128. 

Wallh,  entero-anastomosis,  797. 

Wallis,  stricture,  479. 

WaUs  of  anal  canal,  8. 

Warren,  chronic  constipation,  437. 

Warts,  venereal,  236. 

Watering-pot  fLstula,  403. 

Weichselbamn,  adenoma  of  the  rectima,  723. 

Weir,  appendicostomj-,  166. 

bulb  for  artificial  anus,  886. 

extirpation  of  the  rectxmi,  843. 

manual   examinations.   111. 

method  of  permanent  colostomy,  888. 

temporarj-  colostomy,  166. 
Weist,  foreign  bodies,  907. 
Welander.  venereal  diseases,  220. 
Welch,  malformations,  48. 
Wellbrock,  colitis,  171. 
Wells,  recto-^*ulva^  fistula,  447. 
Wells,  SjDencer,  lipoma  of  the  recto-vaginal 

sseptum,  718. 
Wheeler,  lumbar  colotomy,  862. 
White,  coUtis,  174,  179. 

trophic  ulceration,  288. 
Whitehead,  foreign  bodies,  903. 

multiple  adenoma,  732. 

operation  for  hsemorrhoids,  648. 

treatment  of  multiple  adenoma,  735. 


Wilks,  cohtis,  179. 

Willems,  incontinence  after  e.xtirpation  of 

rectum,  854. 
Williams,  carcinoma,  760. 

proctoplasty,  510. 
Winslow,  venereal  diseases,  213. 
Witzel,  malformations,  87. 

method  of  colostomj^,  888. 
Wolff,  venereal  diseases,  214. 
Wollenstein,  159. 
WoMan  duct,  2. 
Woodward,  dysenteric  ulceration,  284. 

recto-vesical  fistula,  439. 
Woiinds  of  rectum,  915. 

abscess  from,  918. 

delayed  sj-mptoms  in,  918. 

fistula  from,   918. 

from  bougies,  916. 
Kelly's  tube,  916. 
syringe  tips,  916. 

gunshot,  915. 

haemorrhage  in,  918. 

injur\'  to  diaphragm,  in,  918. 
jejunum  in,  918. 
liver  in,  918. 
omenttma  in,  918. 

lacerating,  915. 

Lambotte's  case,  918. 

laparotomy  in,  920. 

multiple,  916. 

operation  for  stone  in,  916. 

principles  governing,  917. 

puncturing,  915. 

results  of  laparotomy  in,  921. 

shock  from,  918. 

sigmoidoscope  in,  919. 

sjTiiptoms  of,  918. 

treatment  of,  920. 

Trendelenburg  posture  in,  921. 

idcerations  from,  918. 

use  of  the  colpeurj-nter  in,  920. 
Wulff,  multiple  adenoma,  734. 
Wyeth,  bougie,  129. 

colitis,  171. 

needle-holder,  387. 
Wylie,  cohtis,  177. 

constipation,  553. 
Wymaji,  idiopathic  periproctitis,  351. 

X-ray  in  lupoid  ulceration  of  anus,  204. 
in  mahgnant  neoplasms,  799. 
in  pruritus,  581. 

Zappula,  giunmata  of  rectum,  244. 
Zemann,  statistics  on  carcinoma,  760. 
Ziegler,  myxoma,  722. 
Ziembicki,  recto-urethral  fistula,  433. 


COLUMBIA    ^^^^  .„,,,ated  V.e;»;„°J,„g,  as 


"0^""""°° 


